Dry Eye Causes and Risk Factors

Q: I have worn soft lenses for 20 years, taking them out at night. Things are fine, except that after long flights (10 hours plus) I sometimes experience uncontrollable burning in my eyes. It is excruciating.

This sometimes happens while I am wearing the contact lenses, and sometimes after I have been wearing my glasses on the flight for some hours, and put my lenses back in before landing. The only solution is to take my lenses out as soon as possible. I can't find references to this problem online.  M.

A: As a very frequent flier I can attest to how eye-unfriendly aircraft cabins are. Although it's better in newer planes, recirculated air and very low humidity can wreak havoc on the tear film and eye surface.

Most people do okay, even on long flights, but add in contact lenses  which can help evaporate tears more quickly  and what I suspect is borderline evaporative dry eye, and you can end up with significant disturbance to the cornea. Pain, burning, tearing and light sensitivity are all symptoms of concern, as they suggest damage or irritation to the eyes' surface.

Without examining you, I can't be sure, but I suspect the root cause is meibomian gland dysfunction (MGD) causing evaporative dry eye. Wearing a conventional lens will worsen this, and if the problem is significant enough to occur without lenses, putting them in apparently pushes you over the edge.

Get a thorough dry eye workup and make sure you share your experience on the plane with the doctor.

If you sleep on these flights (and with 10 hours in the air, I hope you do), have a flying companion check to see if you sleep with your eyes slightly cracked open. Exposure, especially in low-humidity environments, could explain your sudden and intense pain.

Try to avoid wearing your lenses on the plane, especially for long flights.

Use a dry eye drop with a lipid base, like Systane Balance or Refresh Optive Advanced Formula, at least once an hour during the flight. Note this isn't recommended while wearing contact lenses.

If you must wear lenses in the air, you might consider trying a single-use daily disposable. From a dryness perspective, Alcon's Dailies Total One is the class leader.

The bad news is that many forms of dry eye are progressive and will worsen without proper treatment. If it is MGD, the problem should be treated sooner, rather than later. It would be wise to seek professional advice, even though your problems are currently confined to airplanes. Safe travels.  Dr. Arthur Epstein

Q: What are the causes of dry eyes? How does eye twitching relate to dry eyes?  E.

A: There are so many causes for dry eye that even a brief answer is well beyond the limitations of this forum. I urge you to read the section on dry eye on this website and the other questions and answers on this page to get a better understanding of the condition.

Q: Last summer my eyes began randomly burning, stinging and watering at times, from the inner corners. I went to an eye doctor, who said I had dry eyes. I tried all kinds of drops and also taking krill oil supplements, but nothing helped.

When it became winter, my symptoms completely vanished. I had no more eye problems at all. Now that it is beginning to warm up again though, they are starting to cause me trouble. What's more, I noticed when I opened the oven to check on a cake tonight, the heat from it stung my eyes and I couldn't keep them open.

This is a huge issue that is seriously affecting my life, as when it was summer, I literally had to pull over while driving almost every day because my eyes would tear up so bad.  L.

A: I know how frustrating this can be. Your symptoms sound like dry eye, but they are a bit unusual, and without examining you, it's hard to say for sure.

In most places, dry eye usually gets better in the summer as humidity increases and worsens in the winter as indoor heating dries the air. Allergens usually increase in the summer and fall way off in the winter, but itching is usually the most frequent sign of allergy.

Your experience with the oven suggests evaporative dry eye, which is usually caused by meibomian gland dysfunction.

You might try either Systane Balance by Alcon or Refresh Optive Advanced by Allergan, as both are designed to help with this issue. If that doesn't help, I suggest you consult with an eye care provider who is expert in managing dry eye to get to the bottom of this.  Dr. Arthur Epstein

Swim goggles help protect eyes from harmful microorganisms and irritation from pool chemicals.

Q: Why are my eyes so dry after being in the pool? Is there any inexpensive in-home remedy? I am seeing double, and it is really irritating.  L.

A: Pool water usually contains chemicals that are quite harsh.

These additives reduce growth of a variety of organisms but are often irritating to the sensitive tissues of the eye.

Waterproof swim goggles should help, and I would advise that you find a well-fitting, comfortable pair that will shield your eyes from pool chemicals.  Dr. Arthur Epstein

Q: I was in a car accident a number of years ago, with some fairly serious head injuries (like permanent blindness in one eye). It also left me with constantly dry eyes. But my eyes now will drip tears whenever I am sweating! Is this a known condition?

Is there any treatment for the dryness? (The tears don't bother me.)  S.F.

A: Sorry to hear of your accident. Losing sight in one eye is terrible. Over the years I've dealt with many patients who have, and with some additional care they usually do fine.

Going forward, you need to be extra careful to protect the remaining seeing eye  that includes regular eye exams.

Tearing is common in patients with dry eye, but from your description, I suspect you sustained nerve damage from the accident. That can contribute to dry eye, but in your case, as your nerves healed, some of the connections got crossed, and now what causes you to sweat also causes tearing. Although it may sound weird, it isn't as uncommon as it sounds. The body will do whatever it can to heal, even if it means using existing "wiring" to repair damage.

This should be evaluated, but if it is, as I suspect, due to aberrant regeneration of nerves and you are not disturbed by the tearing, no treatment is needed.

You may also have dry eye that should be treated. In any case, have someone take a look to be sure.  Dr. Arthur Epstein

Q: I was diagnosed with blepharitis a few years ago. Now I have had multiple tears in each retina over the past month. I take an antidepressant called Pristiq. Could this be the cause of the problems I'm having with the retinas?

Is there someone in Manhattan I can see about how to protect my eyes? The retinologists have all said they don't know why I'm having these tears, and there is nothing I can do to prevent future tears.  S.S.

A: Previous blepharitis and retinal tears are unlikely to be related. Likewise, I am unaware of any association between Pristiq and retinal tears.

However, with your history you should have regular retinal exams to make sure that you do not develop additional tears. You should seek immediate care if you note any signs of possible retinal detachment, including increased floaters, veiling or shadowing or a change in color of your vision.

Manhattan has one the highest concentrations of retinal specialists in the world. I can't recommend any specific doctor, but I suspect your current eye care provider would have recommendations regarding a retinal specialist.  Dr. Arthur Epstein

Q: I have severe dry eyes. Currently I live in a very dry climate, where it could get as low as 9 percent humidity with over 100-degree temperatures during the summer. My doctor told me that the film of tears that covers my eyes is very thin and evaporates quickly. I also keep getting blepharitis.

I'm a retiree, so moving to another place is not a problem. I'm thinking of moving to a small town by the Gulf, if that would cure my dry eyes. It has low pollution, high humidity, very low elevation and fairly moderate temperatures during the winter. Would that help my situation?

Also, which eye drops would be best for me? My doctor suggested Restasis, but it is extremely expensive.  A.J.

A: I live in Phoenix, so I know exactly the kind of environment you now live in. In the hot, dry desert environment, tear evaporation is a major problem. You are fortunate to be able to move so easily. Most folks can't.

The good news is that a move to an area with higher ambient humidity, lower elevation and low pollution should be helpful, but it may not completely alleviate your problems. How much it does depends on the health of your ocular surface and especially the health and function of the meibomian glands. These glands produce a complex oil with every blink that prevents evaporation and helps stabilize the tears.

The best treatment for meibomian gland dysfunction (which from your description I assume you have) is LipiFlow, a procedure developed by TearScience, which clears and restores function to the glands.

Regarding drops, the best contain oils that mimic meibomian gland secretions. These include Alcon's Systane Balance and Allergan's Refresh Optive Advanced Formula. FreshKote is an Rx product that may also be helpful.

I might also suggest that an extended visit to your intended new home would help you decide if the move would make enough difference to justify uprooting yourself from your current home.  Dr. Arthur Epstein

Q: I have had dry eyes for more than two months now. Out of those two months there was one week where my eyes were better but not normal. This happens often, and more during the winter months, but I feel that because they are dry for so long, there is a bigger problem than just temporary dry eyes. Could there be something seriously wrong with my eyes?  T.D.

A: Dry eye is often a result of one or more protective systems that keep the eyes moist failing to work properly. Seasonal dryness seen during winter heating season or summer air-conditioning season, arid environments typical of the U.S. Southwest, or high altitudes as in Denver, are among the things that can stress ocular surface and tear systems, causing worsened dry eye symptoms.

I suspect your "temporary" dry eye isn't really temporary, but just symptoms of dry eye breaking through. It's likely things will get worse over time, and your symptoms will become more frequent.

For that reason, I suggest you get a full dry eye workup so that therapy can be instituted sooner rather than later, when it may be more difficult to properly manage your dryness.  Dr. Arthur Epstein

Q: My eye care provider told me I have a bit of dryness in my eye, and the cause of it is that I spend about eight hours a day in front of a computer.

I've reduced the time I spend before the computer, and the grittiness is gone. But I still feel dryness, but only a little bit. I'm 16 years old, which is too soon for me to have serious dry eye, but I don't know whether it's chronic or not. Is it possible that I can permanently heal my dry eye?  N.

A: The tears and ocular surface work together to keep the eye moist and to insure crisp vision. Dryness usually worsens with age, but it can occur in younger individuals in some cases. Computer use decreases the frequency of blinking, and that promotes evaporation of the tears. That can be either the cause or a factor that contributes to your symptoms.

You might be helped by one of the newer lipid-based dry eye drops that are available at the pharmacy. Because dry eye tends to be both chronic and progressive, if your symptoms persist I would consult with an eye care provider for a full dry eye evaluation.  Dr. Arthur Epstein

Q: I traveled to South Africa this past May. My total flight times were 25 hours going and 30 hours coming back. When I came back to the United States I started experiencing extremely dry eyes.

Dry Eye News

Dry Eyes? Try Yoga

May 2015  Researchers in Japan have discovered an easy-to-learn technique that may help women with dry eyes: abdominal breathing. Also called diaphragmatic breathing, yogic breathing or pranayama, abdominal breathing is essential to the practice of yoga.

Most people take short, shallow, inefficient breaths that originate in their chest. Abdominal breathing, on the other hand, is a conscious, deeper breathing technique where inhalations and exhalations originate in your belly (or, more accurately, your diaphragm). There are dozens of abdominal breathing techniques; all of them help increase oxygen intake and improve blood flow and lymph circulation. Abdominal breathing also has been shown to reduce stress and increase overall feelings of well-being.

And it appears abdominal breathing also can increase the volume of tears on your eyes, potentially relieving dry eye symptoms.

The researchers investigated the relationship between abdominal breathing and tear meniscus volume (the amount of tears that accumulates between the eye and the lower eyelid) in healthy women ages 20 to 54. The participants were randomly assigned to one of two groups  normal breathing and abdominal breathing  and were tested at two separate visits.

During the first visit, the normal breathing group took normal breaths for three minutes; the other group performed "belly breaths" with four-second inhalations and six-second exhalations for three minutes. During the second visit, the breathing techniques were switched between the two groups.

Tear meniscus volume and other measurements were gathered immediately after, 15 minutes after, and 30 minutes after the breathing sessions.

The researchers concluded that abdominal breathing for three minutes increases the secretion of tears in healthy women and that this breathing technique should be considered in the treatment of dry eye disease. A report on the study appeared in The Ocular Surface in January.  G.H.

They have recently become so dry that I am able to wear my contacts for only a couple of hours at a time. I have tried over-the-counter drops to try and relieve my eyes but none have helped.

I was wondering if the pressure of the plane is the cause of my dry eyes? Also, what do you recommend to improve my discomfort?  L.F.

A: As a fellow traveler who has spent many long hours on international flights, I understand just how eye-unfriendly aircraft cabins can be.

In addition to being pressurized  usually to equivalent altitudes of 6,000-8,000 feet above sea level  the cabins also have very low ambient humidity, typically in the low teens, which can make an otherwise asymptomatic person quite uncomfortable.

For most people, the effects of even a prolonged flight are transient and abate within an hour or two. In your case, I suspect you suffered from marginal dry eye to start with, which became apparent and symptomatic after the long flights.

Without examining you, it is difficult to pin down an exact cause, but my impression is that your primary problem is evaporative dry eye, a condition almost always associated with meibomian gland dysfunction (MGD).

Evaporative dry eye may be worsened by some brands of silicone hydrogel lenses, which can attract the lipid that normally serves as a moisture barrier. Lipid attracted to the surface of the lens can disrupt the moisture barrier and often results in worsening discomfort and reduced wearing time.

To properly address your problem, I suggest you consult an eye care professional for a dry eye workup  especially looking at meibomian gland function. Your provider can also rule out other possible issues that can cause dry eye that may have coincidentally developed (thyroid problems, for example).

From a contact lens perspective, be sure you're wearing a modern, wettable lens material and ask your eye care professional about the proper lens care system to use with your lenses. In my experience, patients suffering from dry eye often do better with daily disposable contact lenses.

With proper diagnosis and treatment, comfort should return, as well as your ability to wear contact lenses.  Dr. Arthur Epstein

Q: Sometimes when I cry, tears won't come out of one of my eyes. Why does this happen?  S.

A: Sometimes a seemingly simple and straightforward question can be very difficult to answer. This is one of those times. An examiner would need to know your age, how recently this started, if there are any other symptoms or problems you've noticed, and if it always occurs in the same eye. Even with a careful history, proper diagnosis would require a thorough eye exam.

Because some of the causes can be potentially serious, especially if this is of recent onset, I advise that you consult your eye doctor immediately to rule out a serious eye or health disorder.  Dr. Arthur Epstein

Q: Why do my eyes well up in tears when I'm either reading a book or on the computer?  E.B.

A: There are lots of possible reasons that your eyes tear excessively when you do close work. Decreased blink rate as you concentrate can reduce tear flow throughout the tear drainage system, which can cause tears to well up. More likely, an unstable tear film and deceased blinking will cause reflex tearing.

Many patients who experience this have evaporative dry eye and would benefit from evaluation of their meibomian glands and treatment if appropriate.  Dr. Arthur Epstein

Allergies and Dry Eye

Q: What causes burning and tearing eyes when wearing glasses? Can one become allergic to the material of the glasses? It usually happens when I wear glasses for a extended period. If I remove the glasses, the tearing and burning clear up shortly thereafter.  T.K.

A: Allergy to eyeglasses, both metal and plastic, can occur, but it is nearly always contact allergy  that is, only in areas where frame materials touch the skin. I've never seen eyeglasses cause eye surface allergy or dry eye problems. In fact, it is usually the contrary. Most glasses provide some shielding or reduce drying or allergens getting into the eyes. The fit of the glasses may have some effect on tear drainage, which can be easily checked by your eye care provider, although this is unlikely.

More likely, you have a problem with your eyeglass prescription. Over-correction, induced prism (due to improper lens centering or positioning) or other lens fabrication problems can cause significant eye strain, with symptoms you describe.

My strong advice is to return to your eye care provider and bring an older pair of glasses that you are or were comfortable wearing for comparison and let them evaluate the problem.  Dr. Arthur Epstein

Q: Which allergy medication can you take that won't affect dry eye?  P.P.

A: Many oral allergy medications cause drying, so when possible I recommend that dry eye patients avoid them. However, most modern topical allergy drops have little impact on dry eye. Some may actually reduce some of the inflammation caused by any allergic reaction.

Q: I was told I had an allergic reaction to my Claritin, and I was given cromolyn sodium ophthalmic to get rid of it. But I have been using it every night for a month and have seen no results. My eyes are still really irritated and burn all the time, and artificial tears only help so much. I am 13. Why are the medications not helping, and why are my eyes dry?  A.M.

A: An allergic reaction to Claritin drops would be most unusual, since the active ingredient in Claritin is ketotifen, which is an antihistamine  the primary class of drugs we use to treat allergy. Cromolyn drops are an older mast cell stabilizer formulation used to treat allergy that some studies have shown to be ineffective in the eye.

Both drops contain preservatives, which I suspect is the more likely cause of your irritation. Preservatives are by nature somewhat toxic and can be irritating to the ocular surface. One option is to discontinue your current drops and use a non-preserved tear until your eyes quiet down.

Even though I believe the cause of your problems is the medications themselves, it would still be wise to consult an eye care professional.  Dr. Arthur Epstein

Q: Recently I have been using Zaditen. I do have dry eye. Problem is, I can't stop using it. Every time I take myself off it, my eyes get scratchy and itchy. Here in Melbourne it is and has been a bad allergy/hayfever season.

Am I at any health risk by constantly using Zaditen drops (in the vial)?  S.L.

A: Zaditen, a brand name for ketotifen drops, is an antihistamine that is usually quite effective for treating eye allergies. It can cause some irritation upon instillation, but that is usually transient.

I suspect the bad allergy season has gotten to your eyes, and the Zaditen is doing its job.

Keep an eye (pun intended) on allergen counts. When they start to drop, you should be able to discontinue the medication. For now, there is no harm in taking it as directed on the vial.  Dr. Arthur Epstein

Q: When I am tired  or lately it's been happening more often  my nasolacrimal duct gets very itchy. Could you tell me why this is happening?  V.

A: Itch is usually associated with allergy. You may be allergic to something in your environment. Itch can also be caused by toxins released by bacteria on the lids that often accompany meibomian gland dysfunction, a primary cause or contributing factor in evaporative dry eye.  Dr. Arthur Epstein

Q: I'm 26 years old. In 2009, I went to urgent care because it hurt my eyes to have them closed, open  you name it. They said that I had an allergic reaction and it would clear up. Well it's 2013 now, and the dry eyes are just as bad. I get allergies where my eyes will stream tears all day and then remain like a desert. I don't take allergy medications because they don't work for me.

I've seen four different eye doctors and one that told me to take doxycycline hyclate 50mg pills twice a day for two months. I followed the instructions to a "T." The irritated bumps and redness inside my eyelids seem to have gone away almost by 60 percent I'd say.

I still have dry eye, and now that I've run out of insurance, I can't afford to go back to see my eye doctor. My dry eyes affect everything: my job, how long I can stare at computer screens, etc. I've done all the omega-3 you can imagine. What can someone like me do? My eyes are either streaming tears from allergies or dryer than the desert. I went to a place to get involved in a trial, and they said I had the lowest oil levels they'd ever seen  38 and 36 in each eye.  A.R.

A: I am really sorry to hear about your problems. They sound severe and disruptive. I am not sure you have allergies. Allergy is almost always associated with itching that you don't describe, and excessive tearing is a frequently seen symptom of dry eye. Irritation causes excessive tearing, which disrupts the balance of normal tears.

You mention that you don't have insurance, so my usual advice, to consult an eye care provider with dry eye experience, may not work. From what you describe, it sounds like you have fairly advanced evaporative dry eye caused by meibomian gland dysfunction. This produces a lack of lipid and excessive tear evaporation and instability. LipiFlow, a breakthrough treatment by TearScience, is the most effective and long-lasting therapy for this condition, but it too is not covered by insurance.

You may get some relief using warm compresses applied to the lids (very warm but not hot enough to burn the delicate skin of the lids), followed by massage of the lids. The technique should really be taught by a doctor, though.

Lipid-containing drops like Alcon's Systane Balance or Allergan's Refresh Advanced are also recommended, as they can help restore lipid levels in the tears.  Dr. Arthur Epstein

Q: My son is active in swimming and water polo. He frequently suffers severe eye irritation during and after water polo matches. Players aren't allowed to wear goggles. Symptoms are severe burning, itching, blurry vision and sensitivity to light. Are there any remedies?  R.W.

A: Your son's symptoms suggest that he is sensitive and possibly allergic to something in the pool water. Severe burning, blurring and light sensitivity are symptoms typically caused by irritation of the cornea, which justifies your concern. I urge you to have your son examined by an eyecare professional.

Because the surface of the eye heals quickly, the examination should be conducted as soon as possible after he exits the pool. Alerting the doctor's office when you set up the appointment would be wise so they are expecting your son when he arrives. Although goggles aren't allowed, in this case they may be medically indicated and, with your doctor's help, an exception may be possible.  Dr. Arthur Epstein

Cataract Surgery and Dry Eyes

Q: Is it safe to have cataract surgery when dry eye syndrome is present? Can severe dry eye mimic cataracts?  M.T.

A: In general, dry eye should be addressed before surgery. However, the best person to answer that question for you is the surgeon who will perform the cataract surgery.

Severe dry eye can disrupt vision, as can cataract. The difference should be very obvious to an eye care professional.  Dr. Arthur Epstein

Q: For people with extremely dry eyes, which type of cataract surgery is better: blade-type or laser-assisted? Or does it matter?  N.T.

A: There are many variations in cataract surgical technique and technology. I suggest that you discuss your concerns with your surgeon. He or she would be the best person to offer advice about the surgery.  Dr. Arthur Epstein

Q: I have severe dry eyes and am no longer able to wear contact lenses. I have punctual plugs (four). Am I a candidate for IOL implants?  J.M.

A: Cataract surgery can worsen dryness, so it's important that the cause of your dry eye is identified and treated. I would discuss your dry eye issues with your surgeon, but IOLs should be possible.  Dr. Arthur Epstein

Q: My wife recently had cataract surgery and now has dry eye. Is that common, and what can be done for it?  F.N.

A: Dry eye is not infrequent after cataract surgery. It can be caused by the surgery itself, the medications used during or after surgery or sometimes just the emergence of dry eye that was going to become a problem eventually.

In many cases, it will improve as the eye continues to heal. I suggest you have her start using a branded drop for dry eye like Alcon's Systane Ultra or AMO's Blink and give it a month or two.

In the interim, it would be prudent to discuss it with her eye care practitioner at her next checkup.  Dr. Arthur Epstein

Computers and Dry Eyes

Q: I am a student of IT. Most of the time I have to be on a computer. While studying I often feel dryness in my eyes and sometimes a severe headache. My eyes feel like they need water.  G.

A: Your dryness is likely due to reduced blink rate, which is common with computer use. But your headaches may be caused by a problem with aiming or focusing your eyes. Both conditions can occur at the same time.

You could try a lipid-based drop like Systane Balance, but it would be wise to consult an eye care professional in any case.  Dr. Arthur Epstein

Q: My eyes tear up every time I use a computer. Is that normal?  R.B.

A: Excessive tearing while using the computer is not normal and may be a sign of irritation caused by dry eye. We have known for a long time that computer work decreases the blink rate. Decreased blinking can reduce the production of essential oils that stabilize the tears and prevent evaporation. This can cause dry eye symptoms, including excessive tearing.

In addition to using a lipid-based dry eye supplement drop such as Systane Balance, initiating blink exercises might be helpful. If you have an iPhone, you can even get an app to help. If you don't have an iPhone, search the Internet for "Korb blink exercise" to get instructions.  Dr. Arthur Epstein

Q: Why are my eyes very painful and why do they produce tears a few minutes after using a computer?  S.N.

A: If the discomfort always occurs after computer use it is most likely dry eye or eye strain. Because it is impossible to accurately diagnose your problem without an examination, I recommend you see an eye care provider. Pain can be a sign of more serious issues.  Dr. Arthur Epstein

Q: I am a pharmacy student in Bangladesh, and I have problems with my eyes when I spend a long time in front of the computer. I feel better only when I close my eyes.

My doctor suggested that I use povidone eye drops (10 mg). But the pharmaceutical company where I work is centrally air-conditioned. Could this be causing the problem with my eyes? It's so hard to study. What can I do?  S.S.

A: You are exactly correct. The combination of looking at the computer for prolonged periods of time along with central air conditioning can exacerbate dry eye. When people are using the computer, they have a reduced blink rate. So this results in the eyes staying open longer. When the central air is on  and the vents are blowing directly on you  this can lead to increased evaporation of tears.

This combination can cause dry eye symptoms. Making the effort to blink more often and moving your work station so you are not facing air vents may help you.  Dr. William Trattler

Q: My right eye burns if I spend a lot of time in front of a computer or reading. I drink a lot of caffeinated beverages during the day. I also have gout. Can the level of hydration affect my burning, itching eyes? Can gout affect my eyes?  J.H.

A: I am not aware of gout affecting one's eyes. I suspect that, regardless of whether you have gout, the cause of your symptoms is related to the extensive time that you spend in front of the computer. There is a condition called computer vision syndrome (CVS), and one of its causes is that people fail to blink enough when working on the computer. This is very common and leads to ocular irritation and burning.

Please see your eye care professional, who can examine your eyes and help you figure out the cause of your symptoms.  Dr. William Trattler

Contact Lenses and Dry Eye

Q: I wear contacts. When they get dry, I use artificial tear drops to relieve dryness and moisturize my eye while wearing the contacts. Is that okay to do?  A.

A: You should have no problem using rewetting drops intended for use with contact lenses. But using preserved drops for dry eye and not designed for contact lens use may cause issues due to preservatives.

Stick with a contact lens product, and you should be fine.  Dr. Arthur Epstein

Q: I've had dry eye for 30 years, and I am not able to wear contacts. Is there anything new on the market for this problem?  K.H.

A: Contact lenses and dry eye often don't go well together. However, there have been some new developments that may help you wear lenses again.

Alcon Dailies Total One is a one-day contact lens that uses breakthrough technology to improve comfort and keep the lens wet. It is worth a try. Also, new developments in scleral lenses, which cover almost the entire eye, have been a life saver for some dry eye patients. Not only do they correct your vision, but they could also address your dry eye issues at the same time.  Dr. Arthur Epstein

Q: I have dry eye. Can I still wear contact lenses?  U.P.

A: Dry eye can make contact lens wear more difficult, but it is still possible to wear them with some cautions. First, your dry eye should be well controlled, and any underlying factors, like meibomian gland dysfunction, should be managed.

Lens choice is more critical. A daily disposable is generally best, and I've found that Alcon's new Dailies Total One is excellent for dry eye patients. Also expect to have more frequent visits to your eye care practitioner.  Dr. Arthur Epstein

Q: I have severe dry eye. I am presently wearing daily disposable lenses. My eye doctor has prescribed me various eye drops for dry eye, but it seems that I am allergic to preservatives in the drops. Also, I am wondering if the solution the contacts are in has preservatives, and if so, is there a contact lens available that is preservative free?  D.G.

A: Dry eye and contact lenses often don't mix, so it's great to hear that you are able to wear them successfully. Your problem may be the interaction of the lens and the preservative in the drops your doctor is prescribing. Lenses absorb and can concentrate preservatives, which can cause a toxic reaction. With your doctor's guidance, you may be better off using a non-preserved product that targets the cause of your dry eye and doesn't interact with your lenses.

Daily disposable lenses generally contain no preservative, so that's not a likely cause.

One last comment is to make sure you return for regular check-ups. Dry eye can complicate lens wear and may increase the risk of infection. Professional supervision is very important.  Dr. Arthur Epstein

Q: Is is safe to use color contact lenses if the eyes are already somewhat dry? Are there special daily soft lenses for this?  I.A.

A: Contact lenses, colored or clear, should always be fitted and evaluated by an eye care professional. They should be able to determine your suitability for lens wear.

In general, dry eye can make contact lens wear problematic, so it's wise to get a professional opinion before you try. Also, as you note, some lenses are better for dryness than others. An expert could make the difference between failure and success.  Dr. Arthur Epstein

Q: I wear contact lenses seven days a week for about 15 hours per day and never have any problems with my eyes. Every so often I switch back to wearing my glasses for about three days, to give my eyes a break. Pretty much straightaway my eyes become very dry, and I develop a headache that generally lasts until I switch back to my contact lenses.

I have tried a number of different eye drops for tired eyes to see if I could alleviate the problem, but so far nothing has worked. Can you advise me where I might be going wrong?  V.

A: It's hard to say without actually seeing you, but from your description, I suspect that your lenses or lens care product is causing irritation. As long as the lenses are in your eyes, they can act as a bandage and reduce any irritation. Take them off, and the irritation becomes apparent.

A second possible issue is that your spectacle prescription may be off, and that is causing your headache. In either case, it would be wise to have your eye care provider take a look and make sure there are no problems with your contact lenses or eyeglass prescription.  Dr. Arthur Epstein

Q: My "dry eyes" tear constantly. This causes my gas permeable contact lenses to fog, and I can't see clearly. Is there anything I can do?  P.M.

A: Excessive tearing is a common sign of dry eye. Tearing comes from tear film instability, often due to meibomian gland dysfunction. The excessive tearing is the eye's attempt to "fix the problem."

Unfortunately, the tearing that occurs actually washes away the more normal tears that protect the eye.

Deposits on GP lenses can be worsened under these conditions or can actually contribute to the problem if the fit has changed or the lens surface has degraded.

I suggest you make your lens fitter aware of your issues. They can recommend appropriate treatment or perhaps a change in lens design or material that should address your problems.  Dr. Arthur Epstein

Q: I have Hashimoto's thyroiditis. I discontinued wearing contact lenses because of extremely dry eyes. I needed drops every 15 minutes.

Are there contacts available for me? Also, does this condition exclude me from LASIK surgery? I'm 63.  D.S.

A: First and most importantly, LASIK would be a terrible idea. Your dry eye would likely get worse and could become totally debilitating. Thyroid disease is a major cause of dry eye and can lead to severe symptoms and profound problems.

We have contact lenses that work much better than earlier designs available today  Alcon's Dailies Total One daily disposable being a good example. But my strong suggestion is that your dry eye be addressed first.

In your case, seek an eye care practitioner who specializes in dry eye. There are many ways of improving and stabilizing the tear film. Once you get your dry eye under control, contact lenses can again be a viable option.  Dr. Arthur Epstein

Q: I have had dry eyes for many years. I use Restasis. I have heard about the "band-aid" contact lens that can be helpful to protect your eyes from getting dry. What are your thoughts on this?  C.M.

A: A variety of contact lens types may be helpful in managing dry eye, especially severe forms. Bandage lenses are close relatives of conventional contact lenses, but may be approved or used off-label to protect and help heal damaged ocular surface.

Large rigid lenses, also called scleral or PROSE lenses, isolate the ocular surface from the environment and can be of major help in addressing dry eye-related disease.

Finally, lenses made from amniotic membrane, like the ProKera, can heal even severely damaged eyes and help treat underlying disease.

In most cases, contact lenses are not a primary treatment, but are generally reserved for patients with bad dry eye where other treatments fail. Some of the contact lens options have risks associated with them, including infection, which must be weighed against the benefits. Contact lenses for dry eye should generally be fitted only by a very experienced dry eye-focused eye care practitioner.  Dr. Arthur Epstein

Q: I wear Proclear contacts because my eyes are very dry all the time. The contacts feel dry even if I soak them all night. I put them in and my lenses feel dried out after a few minutes. What can I do? Eyes drops help, but not very much.  R.J.

A: Managing contact lens-related dryness can be complicated. First, any existing dry eye issues must be addressed. For most patients this includes a full dry eye workup with particular attention to the health and function of the meibomian glands. Any issues should be treated, especially those causing evaporative dry eye (EDE). EDE can derail any lens wearer.

The Proclear lens is usually an excellent choice for patients who have dryness. New-generation lenses such as Alcon's daily disposable Dailies Total One can make a huge comfort difference for some.

If you stay with Proclear, lens care product choice may also be a factor. Avoid generic store brands and ask your doctor to recommend a product with an advanced wetting formula. I usually suggest Alcon's Puremoist or a peroxide disinfection system.

Keep at it. With modern lenses and lens care products and our better understanding of what causes lens dryness, you should be able to find a solution to your issues.  Dr. Arthur Epstein

Q: I wore contacts in high school and started wearing glasses after that. I wanted to switch back to contacts, but my ophthalmologist said my eyes currently don't produce enough tears. About 20 minutes after I put my contacts in they were feeling really dry, and my eyes were just tired overall. He said to just wait six months and see if anything changes.

He also said I might be part of the 5 percent of the population that can't wear contacts. I find that a little weird, since I wore them in high school. I'm only 22. Is there anything I need to be doing to my eyes to keep my tear production going?  K.

A: First, if your eyes are so dry that you have been advised that you won't be able to wear contact lenses at your young age, you should have a comprehensive dry eye workup. It's not just concern about your difficulty with contact lenses. If your eyes are that dry at 22, I am concerned about what will happen as you grow older and dry eye tends to worsen.

The first step is to find out why your eyes are so dry. For example, do you have meibomian gland dysfunction and evaporative dry eye, or do you have a disorder that is reducing tear production, or both? Once the cause is understood, in most cases the problem can be managed.

Regarding contact lenses: Once the underlying problem is addressed, there are many new advanced lens materials and lens care products that focus on keeping the eyes moist. A skilled contact lens fitter should be able to find a lens that will provide comfortable wear.  Dr. Arthur Epstein

Dry Eyes Upon Awakening

Q: How possible is it for one to have difficulty opening the eyes (heaviness of the lid) in the morning as an association with dry eyes? The difficulty sometimes comes with temporarily blurred vision. Recently I had conjunctivitis and used Terramycin for it, is that a possible cause? Or should I seek a neurologist?  S.

A: Swelling and fullness of the lids or even irritation to the cornea caused by improper lid closure while sleeping could make it noticeably more difficult to get your eyes open in the morning. If it feels like you are applying normal or greater force to open and they just will not, possible neurological causes must be considered. However, boggy swollen lids that open normally with some effort are more likely related to dry eye and exposure.

In some people abrasion from the pillow can cause significant damage, discomfort and even blurred vision on waking. The resulting sensitivity can make eye opening uncomfortable and slow-feeling.

My suggestion is to consult an eye care provider before seeing a neurologist. The old saying, when you hear hoof beats think horses not zebras, is very apropos here. Most likely the problem has a simpler cause. I don't think the Terramycin drops are a likely cause.  Dr. Arthur Epstein

Q: I get really dry eyes when I sleep. It doesn't matter if it is a nap during the day or at night, they get severely dry. I have tried gel drops and ointments, and neither seem to help. Could this be due to a duct or eyelid issue?  J.

A: You are describing what sounds like classic exposure. This occurs when the eyelids do not form a tight seal during sleep. This exposes the eye to the drying effects of the air and causes extreme irruption  sometimes waking people up from sleep with sudden pain. It is worse in people who lack a Bell's phenomenon  the normal reflex to roll the eyes up protectively during sleep.

The usual recommendation is a bland ointment before sleep. If you are still having issues, I would strongly urge a through workup, since what you are experiencing may be only part of a more complicated clinical picture.  Dr. Arthur Epstein

Q: I have crust on my eyelids when I wake in the mornings. What is the cause of this condition? And can chronic dry eye ever result in blindness?  G.B.

A: Crusting in the morning can have numerous causes. A definitive diagnosis would require a thorough examination by an eye care provider  something I would recommend.

Very severe dry eye left chronically untreated can lead to loss of vision, but with current treatment options this is unusual.  Dr. Arthur Epstein

Q: I had cataract surgery last year on both eyes. I'd like to know what kind of eye drops I can use daily to refresh my eyes in the morning. It feels so good to moisten my eyes after a night's sleep and using a CPAP machine.

I've asked my eye doctor, and he recommends drops I just can't afford. I'm a senior, and at the end of month I only have $1.72 left. My daughter helps me with groceries.  K.L.

A: I appreciate your budget issues. The best drops tend to be the most advanced and also the most expensive. However, any of the generic dry eye drops should be of some help.

From what you've told me, though, you may actually benefit more from a gel or ointment applied before you go to sleep. If your CPAP is drying your eyes, it's often because your eyes don't completely shut at night while sleeping. This allows escaping air to rush over and dry the exposed ocular surface. In this case a thick gel or ointment may work wonders.

I also recommend that you take a look at the products from Eye Eco. They make an excellent line of protective goggles designed to work with CPAP devices. This may be all you need, and it would be a one-time purchase.  Dr. Arthur Epstein

Q: My eyes dry up at night when I am sleeping  it's like they run out of lubricants. It doesn't happen during the day. I have tried eye drops, and they don't work.  T.C.

A: It sounds like your eyes may not be fully closing during sleep. That's not as uncommon as you may think.

I have several suggestions. First, find a viscous gel like Systane gel, or a petroleum-based eye ointment, and apply to your eyes as directed right before sleep. Try the gel first, and if that doesn't help, use the ointment.

Also, if possible, humidify the room, and if you have fans, turn them off. If your eyes partially open during the night, a fan blowing on them will worsen dryness significantly. This should help.

In any case, seeing an eye care professional is wise.  Dr. Arthur Epstein

Q: I have trouble opening my eyelid after a night's sleep. Is this related to a dry eye?  V.

A: Trouble opening the eyes in the morning can have many causes. When we sleep, the eyes are designed to stay shut, to maintain moisture and protect the sensitive and vulnerable cornea. Some people sleep with their eyes partially open, which can lead to irritation and light sensitivity, making it hard to open the eyes to the morning light.

Occasionally, excess mucus can partially "glue" the eye shut, which can also happen in the presence of infection.

There are other possible explanations that should be investigated by an eye care professional if this continues to trouble you, especially if it worsens.  Dr. Arthur Epstein

Eye Bumps, Eyelid Bumps, and Dry Eye

Q: I have chronic dry eyes and use Restasis. I have a stye on my eye every few months. Is the moisture that I'm getting from the Restasis causing me to get these styes? I was using two drops every few days, then started using it twice daily. The stye came after using it twice a day, every day.  B.

A: Styes are unlikely to be related to your use of Restasis. They are more likely caused by problems with your meibomian glands, which are probably obstructed. This is an extremely common cause of dry eye and may be contributing to your overall problems. I suggest you have an evaluation by your eye care professional.  Dr. Arthur Epstein

Q: I get tiny blisters on the inside of my eyelids all the time. Could it be dry eyes? Would dry eye drops help?  C.

A: I am not completely certain of what you mean by "blisters." Red or gelatinous bumps beneath the upper eyelid are usually signs of allergy or certain types of infection. The bumps you describe are unlikely to be directly caused by dry eye.

It would be wise to have them evaluated by an eye care professional.  Dr. Arthur Epstein

Q: My question is about the small, clear to whitish bumps that have been in my eyes for more than three years. They are located on the inside of the lower eyelid in the corner. I have three to four bumps in one eye and one to two bumps in the other. These bumps have not changed in size or quantity in at least three years. I have no eye discharge or irritation.

An ophthalmologist diagnosed these bumps as allergic conjunctivitis, but that was three years ago and they are still there.

I also have smoked marijuana for about seven years, and I have been trying to detox myself for the past two weeks. This is because I'm starting to think that the marijuana use has caused my eyes to be dry, which could be the cause of the bumps.  J.

A: First, I would recommend that you have another eye exam, since you noted that it has been more than three years since your last exam. During that visit, your eye doctor would be able to evaluate your eyes and determine what these bumps are. I cannot figure them out without examining your eyes.

You bring up smoking, and it is important to note that smoking of any kind has been associated with dry eyes. So, in general, dry eye patients should avoid smoking.

I am not aware of any specific studies looking at marijuana use and worsening of dry eyes. But since this is a form of smoking, it is likely that the smoke can irritate the eyes and worsen dry eyes.  Dr. William Trattler.

Q: Can chronic dry eye cause a white bump next to the colored part of the eye?  H.

A: A white bump next to the colored part of the eye is called a pinguecula. This is caused by UV exposure, although dry eye can cause inflammation that can exacerbate the pinguecula.  Dr. William Trattler

Q: I have a white bump on my upper eyelid near where your upper and lower eyelids meet on the side of the eye closer to the ear. The bump looks similar to a pimple. My eye is very dry and it hurts to blink. Help?  A.G.

A: A bump on the eyelid is most commonly a stye, but it can be a benign or even a malignant form of cancer. Please see your eye doctor, who can help determine what the "bump" is, as well as the best way to treat the bump.  Dr. William Trattler

Q: I have a bump on the white part of my eye. It is a little red and irritating. Is that something serious?  J.J.

A: You are describing either a pinguecula or a conjunctival lesion. I cannot know whether this is a benign or serious condition. Please see your eye doctor to determine exactly what this "bump" is. Note that dry eye can irritate bumps on the eye. So lubricating drops are something to consider as well, once you have seen your doctor.  Dr. William Trattler

Eye Drops and Ointments

Q: Can I use lubricant eye drops at night and in the morning? Or just at night?  J.

A: You can use whatever drops help you whenever you like. If you are using any drop more than six or seven times a day, it might be worth investigating whether a different drop would be more effective.  Dr. Arthur Epstein

Q: Is there a natural alternative to Restasis? I don't like being on Restasis.  R.

A: Restasis is an FDA-approved medication containing cyclosporine. Currently no natural alternative products are available with a similar formulation. However, there are other approaches to managing dry eye that may be helpful. See your eye doctor.  Dr. Arthur Epstein

Q: I have dry eye  particularly at night when I'm sleeping. I was told to use TheraTears Liquid Gel. I used it one night and woke up drier than I have ever been when using the daytime Systane Ultra or Systane Balance. Is there a prescription product for nighttime dry eye relief?  C.A.

A: Nighttime dryness is typically associated with a failure of the lids to close completely. Drying occurs within the gap between the lids, and symptoms can be severe. Generally gels will not persist long enough to help, so we usually prescribe a petrolatum-based ointment like Systane Nighttime or Refresh Lacri-Lube. I hope this helps.  Dr. Arthur Epstein

Q: Can too many Systane eye drops hurt your eyes?  K.

A: Systane is a very safe product. But like any dry eye product, if you are using it more than six times a day, it may be wise to see if a different formulation may be more effective for you.

That said, I don't think Systane used even frequently is likely to hurt your eyes.  Dr. Arthur Epstein

Q: I have a prescription for Ilotycin 0.5 percent. Can I use a dry eye ointment as well at night, as I have dry eyes?  P.M.

A: Ointments for dry eye are used for very specific purposes, such as exposure caused by the lids not completely closing. I recommend that you check with the doctor who prescribed the Ilotycin for its indicated use. I wonder if he or she didn't intend for you to use it before bed?

I would not add any other product to the mix without first checking.  Dr. Arthur Epstein

Q: I find that using either natural tears or lubricant eye drops help my dry eyes initially, but after a few days they make my eyes feel worse. What to do? I will not have plugs put in or use the expensive Restasis.  R.

A: You are asking an impossible-to-answer question. I can't advise you on the best treatment without knowing the cause of your problem.

Most eye drops currently available on the shelf either add more moisture or bulk up the tears with unnatural substances like methyl cellulose. While that can offer temporary relief for some, it is rarely an effective long-term strategy. The tears are very complex, and simple wetting agents disrupt their structure and balance.

You might try one of the newer products like Alcon's Systane Balance or Allergan's Refresh Optive Advanced to see if they help, but you really need to consult with an eye care provider who is dry eye-focused. There are many other treatments besides Restasis and punctal plugs that may be more effective for you.  Dr. Arthur Epstein

Q: I have dry eyes and use natural-tear eye drops every day, which usually helps. But since the weather has been warm, they seem to be worse, and the eye drops soothe for only a short while. I have to use them more each day. I was wondering if the summer would make my eyes more dry and if there is anything else I could use?  L.I.

A: Dry eye usually affects people year-round, but severity can vary over the course of the year. Air conditioning during the warm months can reduce humidity indoors and worsen dry eye. The rapid cycling between higher humidity outdoors and lower humidity indoors can also present a challenge by destabilizing the tears. Finally, greater exposure to allergens during the spring and summer can increase baseline inflammation and worsen dry eye.

To manage this, consider a lipid-based dry eye drop, which can help reduce evaporation. Also have your optometrist or ophthalmologist check to see if you suffer from meibomian gland dysfunction, which may be a contributing factor.  Dr. Arthur Epstein

Q: I have dry eyes 90 percent of the time (mostly my right eye). The specialist told me to just use eye drops like Refresh. They don't work for long.

I also get white bumps on the edge of my eyelids sometimes, and I have to scrape them off with my fingernail. My right eye feels like there is always something in my eye. The location of the problem seems to be just right off-center of my upper eyelid.

I have to blink a lot, and this makes my eyes hurt sometimes. Plus my nose gets sniffly. My left eye is not as bad as my right. Do I need a better eye drop?  S.

A: From your description it sounds like you have fairly advanced meibomian gland dysfunction. That needs to be treated by an eye care practitioner.

In the interim, an artificial tear containing a lipid supplement might be helpful. Systane Balance or Refresh Optive Advanced Formula are two good examples. Also, it's not unusual for one eye to be worse than the other.  Dr. Arthur Epstein

Q: I have very bad dry eyes. I used Restasis for three months, but it doesn't work for me. Now I'm using TheraTears. I was better for about 45 days, but now my eyes are bad again.  E.

A: Restasis is effective for some people and not for others. Keep in mind that dry eye often has a number of underlying causes and tends to be progressive.

TheraTears is an excellent product, but it's likely that it did not fully address the actual cause of your dry eye. You might try a lipid-based supplement like Systane Balance or Refresh Optive Advanced Formula. If those products don't help, you need a thorough workup by an eye care practitioner who focuses on dry eye and ocular surface disease.  Dr. Arthur Epstein

Q: I was recently diagnosed with dry eyes by an optometrist who handed me a sample size of Refresh Liquigel eye drops. And in fact they are drops and certainly not a gel.

She said my eyes were dry, but not too bad, and recommended drops up to four times per day. She said at night I might want to use a real gel, a much thicker sort of product.

So this morning I was pricing out these drops and was a bit surprised at their cost, which prompts this question: Can you provide me the names of products similar in function and quality to Refresh Liquigel eye drops?

I am a bit confused as to the nature of the "gel" part of Liquigel and how important that is. My local Costco carries some Refresh products and some Systane products, but does not carry Refresh Liquigel. And frankly, is there a generic product I could find in a Kroger, Walgreens or Walmart that would work as well?  J.

A: Tears are extremely complex, and we've learned over time that older tear supplements lacked the structure or function of normal tears. Several products come much closer to having the protective and functional qualities of natural, healthy tears.

While some name-brand products are carryovers from the past, all of the generic store brands I am aware of are little more than water and thickening agents. I realize that the major brand products are expensive, but they generally are better at addressing specific problems.  Dr. Arthur Epstein

Q: I have been on steroid drops for seven months for dry eye syndrome. My eyes are no better. Is it possible I have been misdiagnosed?  B.L.

A: Steroids reduce inflammation and also have a number of potentially serious side effects. For that reason, most clinicians use steroids for only short periods.

Since they target inflammation and you are getting no relief, it suggests that your problem is not inflammatory in nature. In that case, I see little benefit in continuing them. I would check with your doctor to see if they have a recommended discontinuation protocol.  Dr. Arthur Epstein

Q: I've had what I figure are dry eyes for quite a while now. I used Opcon or Naphcon for years, more in association with allergies. But I discontinued use two or three years ago, because use became more frequent, yet I experienced more redness.

My eyes always feel somewhat irritated and tired, with moderate redness, and I have always been sensitive to sunlight. Indoors, fluorescent lights in particular also seem to bother me, far more so than incandescent.

I blink frequently, but oddly enough, the irritation is at its worst when I'm around people, friends, customers, whoever, but more significantly if I'm talking with someone one-on-one. This particular aspect has become most apparent in probably the past two years. Go figure!

It's embarrassing when I am trying to look someone in the eye during our conversation and have to make a hard, squinting blink to ease the irritation in my eyes. The unpleasant sensation seems to be in the lids where they contact the eyeball itself.

I've considered trying an OTC remedy but am not really sure which one to try, if that is indeed what I need for this condition.  J.B.

A: I'll start with the Naphcon and Opcon use. It's good that you stopped. Regular use of decongestant eye drops leads to rebound redness and for many people more and more frequent use. Most eye care practitioners advise patients to avoid these drops except for rare use when they must whiten their eyes for a specific event. Regular use is a no-no.

Regarding the light sensitivity, it's one way your eyes are telling you there is something wrong on the surface. In a sense it's nature's way of protecting the eye, by making you want to close it. You should have this checked out by an eye care professional.

I can only speculate why your problems are worse in the presence of people. There is a portion of the lid that we call the "lid wiper," and it's possible that it is chronically irrupted. Even more likely as a cause is inhibition of blinking while you are conversing with people. The more attention you pay to them or, for that matter, anything that you intensely attend to, the less frequent your blinks become.

Blinking serves many purposes. One is to help express the complex oils that your meibomian glands produce. These oils stabilize the tears and improve their surface quality. They also help clear tears and any contaminants that have built up within them. From your description, I would assume you have problems with how you blink  frequency and completeness and probably meibomian gland dysfunction.

Since your situation is fairly complex, I urge you to find a dry eye-savvy eye doctor and set up an appointment. It sounds like you are really uncomfortable and beyond simple over-the-counter remedies.  Dr. Arthur Epstein

Q: What is the best brand of OTC eye drops? I have used several expensive ones, and they have not helped much.  F.P.

A: I am not sure there is a "best" brand. The major brands tend to have advanced formulations that can be very helpful depending on the cause of your problem. If you have experimented with a variety of different products and none have offered much relief, I suspect your dry eye is complex and you would benefit from seeing a dry eye-savvy eye care provider.  Dr. Arthur Epstein

Q: Will over-the-counter eye medication help dry eye?  S.L.

A: Today, over-the-counter eye drops are much more sophisticated and advanced than ever. Some can make a huge difference for some patients.

I should add that the best performance is usually obtained when a specific OTC product is recommended by an eye care professional based on the specific cause of your problem.  Dr. Arthur Epstein

Q: On and off, my left eye gets very dry. I try putting in eye drops, but it helps for only a little bit. Can you please provide me with some recommendations to make the dry eye better?  L.

A: Almost all drops for dry eye are available over the counter. If one isn't working, you might try another. Because most dry eye involves evaporation, I often recommend lipid-based products like Systane Balance or Refresh Optive Advanced.

Keep in mind that your problems may be too advanced for drops alone or may be due to issues other than dry eye. If your problem persists, I recommend you consult with an eye care provider.  Dr. Arthur Epstein

Q: I have a subconjunctival hemorrhage from a head injury that I got over a week ago. My eye is healing great, but now it is very dry. I was wondering if I could use eye drops?

If so, I have a bottle of Blink gel tears and a bottle of a generic redness reliever. Would either of these two be OK to use, or do I need to buy another kind?  B.V.

A: I am glad to hear your eye is getting better. Drops should offer some relief while your eye recovers from the trauma. Blink drops should be fine, but you might want to try a drop that contains a lipid additive, like Alcon's Systane Balance or Allergan's Refresh Optive Advanced Formula, which may offer a bit more protection and lubrication while your eye heals.

If you are not back to normal in a month or two, I would discuss it with your eye doctor to make sure there are no other problems.  Dr. Arthur Epstein

Q: I use Refresh eye drops for dry eyes. They told me a new one is out called Hylo. Is there any difference between them? Because there is a big difference in price.  M.

A: I have no experience with Hylo, but a search on the Internet suggests it uses hyaluronic acid as its primary wetting agent. Since dry eye is caused by a number of different factors, it might offer greater relief, or it might not.

Q: Out of all the artificial tears available at places like Walgreens and CVS, which eye drop might be the most successful at treating any mild to moderate dry eye?  J.J.

A: These days, artificial tear supplements are much more complex than they once were. This allows us to target specific problems with different formulations. For most patients with mild to moderate dry eye, I most often recommend Alcon's Systane Balance, which is an advanced formulation targeting all components of the tears. There are many other excellent products on the market as well.  Dr. Arthur Epstein

Q: How many types of drops should be taken every day in each eye for dry eye?  E.D.

A: Asking how many drops you should take is like asking, "How much is enough?" The number of drops will vary depending on the product, the severity of your dry eye, ambient humidity, the cause of your dry eye and dozens of other factors.

As a general rule, you should use tear supplement drops no more than recommended on the package labeling or six times a day  whichever is greater. If you find you need to use them more frequently, I urge you to consult with a eye care provider with expertise in dry eye management. Too many drops can actually "wash away" healthy tears and compound your problem.  Dr. Arthur Epstein

Q: What is the best eye drop that I can buy over the counter for red eyes? I'm working in TV production and am surrounded by spotlights. That is why my eyes are dry and turn red.  V.

A: I wish I had a good answer, but it's hard to make a recommendation without knowing the cause of your red eyes. Redness usually occurs as a sign of an underlying problem. Taking a drop to mask the redness will not address the issue.

Some over-the-counter drops can actually make redness worse over time. Also, the more often you use many red eye drops, the more often you will need to use them to reduce redness, creating a vicious cycle.

I suggest that you have an eye examination to find the cause of your problem so an effective treatment can be found.  Dr. Arthur Epstein

Q: I was recently diagnosed with inflammatory dry eyes and was prescribed Restasis. However, my insurance does not cover it. Is there anything else that is going to work as well for me?  S.

A: Currently, Restasis is the only anti-inflammatory product approved for treating dry eye. Other products are in the FDA pipeline, but their timing for approval is uncertain.

You might discuss this with your eye care provider. There are other strategies that may help, including limited use of topical steroids, nutritional support and possibly ways of improving the quality of your tears that can help reduce inflammation. This can be determined after an examination.  Dr. Arthur Epstein

Q: I get extremely dry eyes during the winter. Sometimes it's from using a computer, but not always. I use Systane eye drops, but they haven't helped a lot. What would you suggest I use?  T.

A: It's not uncommon to have dry eye when heating season begins, as the air inside dries out. Also, computer work decreases blink rate, which can make your symptoms worse.

Systane is an excellent line of dry eye products; however, there are several types that target different aspects of dry eye. From your symptoms, my thought is that you may have more of an evaporative form, and Systane Balance would be first choice in that case.

It's also important to remember that drops are only one part of effective dry eye therapy. If your symptoms persist or worsen, I suggest you consult with an eye care provider who focuses on dry eye.  Dr. Arthur Epstein

Q: I use Restasis intermittently for dry eye. My eyes burn and have pain almost constantly. I will experience burning and pain in one eye for several days, and then it will stop and the other eye will start burning with sharp pain.

Should I be daily consistent with the Restasis? Perhaps that will help? Or is there something else I should be addressing?  J.G.

A: Dry eye can cause pain, but what you are describing is unusual and should be evaluated by an eye care professional. If you are taking Restasis, or almost any other medication for that matter, consistency and following labelled or doctor's instructions is important for the medication to be effective. This is especially true for Restasis, where the effect can take time.  Dr. Arthur Epstein

Eye Infections and Dry Eye

Q: If someone has dry eyes, would that cause them to get more infections of the eye than someone who didn't have dry eyes? I'm assuming there is less lacrimal fluid there to clean the eye.

What if drops were used? Would that help to lubricate the eye and move around the lacrimal fluid, or would it just dilute the lacrimal fluid and not help?  T.S.

A: That is a great question. I suspect that most eye doctors believe that dry eye is associated with a greater risk of infection due to decreased tear volume and ocular surface damage. I do not believe this perspective has ever been supported by rigorous scientific investigation.

Normal tears contain a variety of antibacterial agents that are likely reduced in dry eye. How much artificial tears would reduce the relative concentration is unknown compared with the positive impact the drops would have on ocular surface integrity.

My approach is to restore tear stability and volume and minimize damage to the surface. Logically, this should reduce the risk of more serious complications like infection, but because of the complexity of the ocular surface and tears it is difficult to predict which factor would have the greatest impact on reducing possible infection.  Dr. Arthur Epstein

Q: I've been wearing monthly contact lenses for 10 years now and have had a few eye infections. Recently I've been struggling with dry eyes. Could this be due to using soap to wash my face and clean off eye makeup?  L.W.

A: When removing eye makeup, select products that are eye-friendly. Not only are harsh soaps irritating, they can strip the skin around the eyes of essential oils and cause drying and irritation, which can worsen dry eye. Speak to a specialist contact lens fitter about the dryness. There are ways to address your discomfort. Also inquire about these infections.

Frequent eye infections are a serious concern. Are you replacing your lenses as directed? You must also replace your case every three months and make sure that you never, ever top off old solution. Pour out used solution and use fresh every day.

Finally, make sure your hands are clean before you touch your lenses or your eyes. If you have another infection, please consult an eye care practitioner.  Dr. Arthur Epstein

Eye Irritation, Pain, Burning and Watering

Q: I have been told I have dry eye, and my eyes water all the time. How can I stop them from watering?  S.

A: This is a very common question and a source of tremendous confusion for many patients. Dry eye usually causes irritation, and the eye responds by trying to wash away the irritant with tears. The excessive tearing actually further destabilizes the tear structure, making matters worse.

The best way to address the issue is by identifying the cause of your underlying dry eye and treating it. It would be wise to consult a dry eye-focused eye care provider for specific therapy.  Dr. Arthur Epstein

Q: I have dry eye syndrome. My eyes hurt really bad! I've tried drops of all kinds and use them all day, and I use the warming mask. I get the filaments on my eyes that feel like crushed glass in your eye. I've already seen the ophthalmologist to have them removed sometimes, but what can I do to keep them out of my eyes? They hurt! Bright lights hurt, the sunshine, even wraparound shades.

My eyes always burn, itch, sting and are red! I don't know what to do anymore. I've even had my lower tear ducts singed  they thought that would help, but no.  V.L.

A: It sounds like you have advanced dry eye and a condition called filamentary keratitis, both of which can be very painful. Other than removing them manually, there are a number of other ways filaments can be treated, including anti-inflammatory drops, a specially formulated acetyl-cistine drop and, in some cases, bandage contact lenses. Your dry eye must also be treated effectively.

Your symptoms suggest that you have significant ocular surface disease  specifically, problems with your cornea. My suggestion is that you find a fellowship-trained cornea specialist or an optometrist with a strong focus on ocular surface disease who can help you manage your condition. You will do much better once it's under control.  Dr. Arthur Epstein

Q: I'm 24 years old and female. I was born with watery eyes  ever since I can remember, my eyes have been tearing, especially when it's cold and windy. It's slightly painful.

What causes this? It's irritating, and people ask if I'm crying. I can't use mascara or eyeliner because of it.  S.

A: What you are describing is typical of dry eye, but the early age your symptoms started is quite unusual. Excessive tearing is how the eyes respond to irritation. This can include dust, wind and cold or allergens. Sensitivity can be increased by anatomical and other factors.

Since this has been a bother for such a long time and is disruptive, I urge you to see an eye care specialist to determine the exact cause and treatment.  Dr. Arthur Epstein

A: Excessive tearing is among the most common signs of dry eye. What we call dry eye is actually caused by dysfunction of what is a very complex tear film. The eye sometimes tries to compensate by increasing tear production.  Dr. Arthur Epstein

Q: My wife's eyes seem to water excessively. The tears run down her cheeks and often splash her glasses to the point where she has to clean them very often.

We have tried allergy medications without success. There seems to be little difference between seasons or surroundings, though most big box stores seem to be a bit worse than other environments. Any suggestions would be appreciated.  T.F.

A: As odd as it may seem, excessive tearing is often a sign of dry eye. When the surface of the eye becomes irritated, the eye attempts to compensate by producing more tears. Unfortunately, excessive tearing often makes matters worse, as it destabilizes the normal protective tear structure.

I would suggest that your wife try a formulation that helps restore tear balance. Choices include Systane Balance by Alcon or FreshKote by Focus Labs. Both should be available at your local pharmacy. Avoid allergy or eye whitening drops, as these products will often make things worse by irritating the eye's surface.

Finally, much of dry eye is due to excessive evaporation of the tears. If your wife's problem persists, find an eye care practitioner who is dry eye-savvy and have her meibomian gland function evaluated. Meibomian gland oils are key to tear stability and health, and meibomian gland dysfunction may be the root cause of her problem.  Dr. Arthur Epstein

Q: How do you know if you have dry eyes? Almost every day my eyes drip tears. It lasts most of the day, and sometimes there is burning.  J.W.

A: What you are describing are classic signs of dry eye. Excessive tears dripping out of the eyes is called epiphora, and it is very common in dry eye patients. It's your tear system trying to correct for the dryness. The burning in the evening is often caused by meibomian gland dysfunction (MGD).

Both are signs of fairly advanced dry eye, so professional help would be a good idea. Please consult a dry eye-knowledgeable eye care professional.  Dr. Arthur Epstein

Q: I have dry eye syndrome. Why does this make my eyes want to close all the time?  R.

A: If your dry eye is severe enough to be causing irritation to the eye's surface, it can make your eyes want to close. It also cause light sensitivity. If this persists, you should consult with an eye care professional.  Dr. Arthur Epstein

Eye Redness and Dry Eye

Q: I have red, irritated eyes from delivering mail outside. I deliver in the country, and I think it's the wind, sun and dirt roads. I use over-the-counter drops, but should I be using these every day?  J.

A: Frequent exposure to the elements can certainly irritate your eyes. I recommend you get a quality pair of wraparound sunglasses. This will help protect your eyes from the wind as well as UV exposure. You can get a lighter tint if you are concerned about visibility.

As far as drops go, your work environment can be relatively extreme. The outer oil layer of the tears provides protection against evaporation and adds stability. I would recommend a lipid-based tear supplement like Systane Balance or Refresh Optive Advanced Formula as your best bets for extra protection.

Finally, it's always a good idea to have a doctor take a look at any eye problem that's chronic.  Dr. Arthur Epstein

Q: My eyes have been red for two weeks. They are burning and feel a bit dry and irritated. What should I do ? I use Visine and natural eye drops for allergies. I don't know what's going on. Should I get an eye exam?  A.

A: You answered your own question. If you don't know what's going on, you need to see an eye care provider. Your red, irritated eyes may be minor and easy to treat, or they may be a sign of a more serious problem. Get yourself to an eye doctor who can help you.  Dr. Arthur Epstein

Q: My eyes are extremely bloodshot all day long. They hurt, and I blink a lot. I have allergies, which I assume is the problem, but is it more likely to be dry eyes? I find myself lying down and closing my eyes just to get some relief.  K.N.

A: Dry eye and allergies go hand in hand. The less tears you have, because of either a lack of adequate production or excessive evaporation, the more irritating allergens can be.

If you are experiencing itching, the hallmark sign of allergy, I would recommend you try an over-the-counter allergy drop to see if it helps. You can ask your pharmacist for a recommendation.

If it doesn't help, and especially if the redness and irritation persist, you should see an eye care provider to identify the exact cause of your problems so they can be resolved.  Dr. Arthur Epstein

Q: I have dry eye, which has been diagnosed by an eye doctor. How can I get my nice, white eyes back? I have been to three eye doctors, and all the drops they have prescribed have only made my eyes more red.

I have tried every over-the-counter "tear drops" and am taking 2g of omega 3s daily and drinking lots of water.  K.K.

A: Sorry to hear of your troubles. Ocular redness is a frequent complaint among dry eye patients. It typically represents inflammation, which can be caused by a variety of different things.

At the top of my list is meibomian gland dysfunction, which is a disorder of the oil glands in the lids. MGD can be a primary cause or a contributor to dry eye, and it is also associated with overgrowth of staph bacteria on the lids. The staph can produce toxins, which can cause redness.

As our understanding of dry eye increases, its management has become more complex. I urge you to attempt to find an eye doctor who specializes in dry eye. I suspect you'll find appropriate answers there.  Dr. Arthur Epstein

Q: Can you have dry eyes in just one eye? My left eye has two blood vessels that have been red for four months.  P.D.

A: Dry eye signs and symptoms can vary somewhat between the eyes. Sometimes the more involved eye can make the less affected one feel comparatively normal.

While redness is a common sign of dry eye, your description of two isolated dilated vessels in the left eye is not typical. It would be wise to consult an eye care professional to make sure it is not something more serious.  Dr. Arthur Epstein

Q: I'm using Visine Maximum for redness and dry eyes. Starting recently, when drops run down my face I am getting a breakout on my face. What else can I use for redness and dry eyes?  T.C.

A: What you are describing sounds like you are sensitive or allergic to one of the ingredients in the eye drop. That isn't uncommon, and you should discontinue that drop.

Eye redness is usually not the problem, but more typically a sign of something else wrong. Patients with dry eye should avoid products with whitening agents, as they further disrupt the tear structure and worsen dry eyes. The next step is to consult with a dry eye-savvy eye care professional to better understand the cause of your dry eye.

Often, dry eye patients with red eyes have meibomian gland dysfunction, which can be treated effectively. Once the cause is discovered and an effective treatment initiated, the redness should fade.  Dr. Arthur Epstein

Q: My eyes are always so red and dry. I can't cry, and they hurt so bad. It's like a burn, not a sting. I've tried eye drops, but nothing's helping!  A.

A: It sounds like your dry eye is fairly severe. With only this information to go on, it is impossible to properly diagnose the cause or suggest a treatment. However, because dry eye tends to be chronic and progressive it is unlikely to get better on its own.

I strongly urge you to seek professional assistance from an eye care professional with dry eye focus. Sorry I could not be more specific.  Dr. Arthur Epstein

Q: I wear contacts, and it is the dry season here and very dusty. I also recently went swimming in a river but didn't open my eyes underwater. One of my eyes is a little red, and both have felt very dry for the past two days.

I was using over-the-counter eye drops but may have used them too much (more than 20 times in one day). My eye doesn't seem to be getting better. Should I use medicated drops? If so, what kind? Otherwise, should I just keep using the over-the-counter drops but less frequently?  B.

A: As is often the case, it is very difficult to know what the cause of your dryness and irritation is. Even though it is the dry season there, whenever someone mentions contact lenses and swimming, especially swimming in river water, I worry about the possibility of infection. Also, taking over-the-counter medications excessively may be causing your problem, but it could be more serious.

My suggestion is to discontinue lens wear until the problem resolves, and stop taking the eye drops you have been using. If your eye does not feel better in a day or two, and especially if the redness or irritation worsens, I would urge you to seek an eye care specialist for a full examination. If it is an infection, delay will only make matters worse.

If it gets better, wait at least a few days, then carefully clean and disinfect your lenses (or replace your lenses if they are disposable), replace your case, and you can then try to wear lenses again. If you encounter the same issues, dryness may be the culprit, and a professional exam is your best course of action.  Dr. Arthur Epstein

Q: I am plagued with very red eyes when at work. On weekends, my eyes are much less red. They do not feel particularly dry, but they look awful.

I do a fair amount of computer work. Could this be the culprit?  A.S.

A: There are so many causes for red eyes that the differential diagnosis fills a book. Dry eye may be a cause or contributing factor, and your thinking is logical  computer work decreases blink rate, which can worsen dry eye; however, other causes need to be ruled out.

If this has been ongoing, it makes sense to consult an eyecare professional. Your red eyes clearly concern you, and the solution may be quite straightforward.  Dr. Arthur Epstein

Q: I want to know what causes my eyes to be red continuously every day, especially in the morning. It's the eyelashes on the bottom  they get very itchy, and if I rub them at all they go very red. What could I take to get rid of this for good, as I have had this problem for quite a while?  J.

A: Eye redness is a sign of trouble. The lids play very important roles in eye function and protection. What you are describing sounds like blepharitis, an inflammation and/or infection of the lashes and glands in the lid. This is often accompanied by dry eye and sometimes infection.

I advise you to consult an eye specialist, as the diagnosis must be confirmed and treatment prescribed by a licensed practitioner.  Dr. Arthur Epstein

Glaucoma and Dry Eyes

Q: I have just been told I have narrow chambers of the eyes. I have suffered from dry eye for a number of years. Could this have anything to do with the narrow chambers of my eyes?  L.T.

A: People use different terms to describe the same thing or similar terms to describe different things. To me, a narrow chamber refers to the space between the front of your iris and the back of your cornea. Having a shallow chamber would be unusual in a normal patient, and it would have nothing to do with your dry eye.

Of greater concern is that your eye care provider may have been describing a narrow angle, where the iris and cornea meet at their periphery. That is also where the drainage system for internal fluids exists, and if the angle is sufficiently narrow it could possibly close, which would cause acute glaucoma.

The preventative treatment for this is relatively straightforward, so I would suggest you inquire regarding possible prophylactic treatment if you do have this condition.  Dr. Arthur Epstein

Q: My husband has glaucoma, and he is taking prescription eye drops to keep eye pressure down. However, the drops cause him considerable eye irritation and dry eyes. Sometimes, he can't get his eyes open in the morning. Are these eye drops doing more harm than good?  R.R.

A: Excellent question. The chronic use of glaucoma eye drops can lead to dry eye. But if you do not treat glaucoma, blindness can develop.

Many other options also are available for treating glaucoma:

Your husband can ask about laser therapy for glaucoma. This technology can help lower eye pressure typically for about three years. This can give your husband a "break" from the glaucoma eye drops and allow the dry eye to improve. However, eye pressure may not go down enough for him to get off the eye drops.

A preservative-free formulation of Timoptic eye drops for glaucoma is available. This version would be less likely to cause ocular irritation. Obviously, your husband would need to speak with his doctor to see whether he could use this type of medication to control eye pressure.

A few glaucoma medications with milder preservatives also may make a difference. One is Travatan Z, and another is Alphagan P. Milder preservatives may mean less ocular irritation. Again, your husband should ask his eye doctor about this.

I also recommend that your husband ask for an evaluation to determine if dry eye is present. If so, he can be treated with punctal plugs and topical dry eye therapies.  Dr. William Trattler

LASIK/PRK and Dry Eyes

Q: I had LASIK surgery about two and a half years ago. I had some dry eye going into the surgery and came out about the same. Over time, the dry eye has become worse. I have used several types of drops (Restasis, etc.) with no relief. I had punctal plugs inserted and still no relief.

I am at the point now where I use Refresh and/or Systane Balance throughout the day. Sometimes I'm adding drops more than 50 times per day. My eyes feel dry and burning all of the time. I don't know what to do or how I will go on like this.  M.W.

A: Your experience is an example of just how bad and overwhelming severe dry eye can become. I am truly sorry to hear that you are suffering so badly. It is possible that LASIK contributed to your problem, but at this point we can't undo the surgery. Solving your issues and getting you back on track is far more important.

To reassure you, I regularly see patients who have severe dry eye like yours, and a systematic approach often produces dramatic results. This may not happen as quickly as you would like it to, but with patience and persistence it will likely happen.

Severe symptoms such as you describe are often multifactorial in cause. From your description of symptoms I suspect you have evaporative dry eye due to meibomian gland dysfunction.

My clinical intuition also suggests that you have exposure, a condition where your eyes are not closing fully while you are sleeping. This can damage the eye's surface and make your symptoms dramatically worse while you are awake. You also may have a number of other conditions or factors that are contributing to your misery.

The most important thing is that you realize at this point you need professional help. There are many new techniques and methods that can help you. Finding someone who is expert in managing severe dry eye is critically important.

Thankfully, your area (New York City) has many very competent clinicians who routinely manage severe dry eye. One way to find a dry eye-focused provider is to use the doctor finder on www.lipiflow.com. I am hopeful that you will be able to find help.  Dr. Arthur Epstein

Q: I had LASIK surgery just over a year ago. It was very successful, if not painful! I had stopped using lenses due to discomfort and decided to take the plunge. I would rub my eyes a lot to produce tears when my lenses dried out; sometimes they would fall out from lack of lubrication.

I work in front of a computer for 10 hours a day. I notice that some evenings or in the mornings after a late night my eyes are dry and need drops, as sometimes tears are not produced adequately to stop the dryness, accompanied by slight blurriness. Are these symptoms of chronic dry eye as a result of the surgery? Or is it me being more sensitive to the state of my eyes as a result of my fear of regression?  S.C.

A: LASIK is often associated with dry eye after the surgery, but for most, the condition is temporary and improves within a few months. That doesn't mean that you will not develop dry eye that has little or nothing to do with the surgery.

If your symptoms persist, consider a dry eye drop that contains a lipid supplement  Systane Balance by Alcon being a good example. If this fails to resolve your problems, it would be wise to consult with an eye care professional to see what other treatment may be helpful. Dry eye is usually progressive and better treated early.  Dr. Arthur Epstein

Q: I had LASIK surgery about 10 years ago. I am 60 years old and have also had cataract surgery in one eye. I have severe dry eyes.

I am on Restasis twice a day, have tear duct plugs, and use Systane drops several times a day. There are times that all I want to do is close my eyes to get temporary relief. Nothing seems to work. What else can I do? I am miserable!  C.R.

A: Sorry to hear about your problem. You are not alone: many people are downright miserable because of dry eye. You have a number of factors that predispose to more severe dry eye. Eye surgery, especially LASIK, can cause or worsen dry eye, as can cataract surgery. Usually this improves over time, but in your case, it sounds like it hasn't.

Without actually seeing you and judging only by your description, I suspect you have evaporative dry eye or EDE. It's the reason you close your eyes to get relief. EDE is usually caused by meibomian gland dysfunction. Restasis often will be of little benefit to patients with EDE. Also note that Restasis and punctal plugs do not function synergistically.

The most effective way to treat EDE is using the new LipiFlow system. You can find a doctor near you by searching for Lipiflow online.  Dr. Arthur Epstein

Q: I had LASIK eye surgery six months ago, and now I have a dryness problem. I am using artificial eye drops. Do you think they are harmful to my eyes, and can I use them for a long time? Also I am using a computer for seven to eight hours a day, so how can I protect my eyes from dryness?  H.P.

A: LASIK surgery often causes dry eye, usually lasting several months after the procedure and sometimes longer. While drops can be helpful, modern drops target different causes for dry eye. Because other factors, beyond the LASIK procedure, may be contributing to your dry eye, it would be wise to discuss this with your surgeon or eye care practitioner. But in general, most drops will not cause significant harm, provided you use them as directed.  Dr. Arthur Epstein

Q: I had PRK laser eye surgery performed six months ago and I've recently noticed my eyes have become increasingly dry. Even with my daily dosage of drops, at least 10 a day in each eye, they are still dry. My eyes are so dry the sclera bunches up by the tear duct when I look from left to right. Silly question, but do I need to be worried?  D.M.

A: Dryness is not uncommon after refractive procedures, including PRK. In most cases, the symptoms begin to abate about six months after surgery. For some, a return to normal can take longer, so your symptoms may yet resolve. However, your frequent use of drops and your description of the surface of your eyes suggest a dry eye workup at this point would be wise.

What you describe as bunching up of the sclera is more likely conjunctival chalasis  a bunching up of excess loose conjunctival tissue, which is clear and overlies the sclera. This is fairly common in adults and may be associated with irritation similar to the symptoms of dry eye. The excess tissue may also disturb normal tear flow, which can worsen existing dry eye. A thorough examination will help pinpoint the cause so that effective treatment can be initiated.  Dr. Arthur Epstein

Medications That Cause Dry Eyes

Q: Can Losartan (high blood pressure medication) be the cause of my very dry eyes and dry mouth? The label states it causes dizziness, and that can be caused by inner ear dehydration. Doctors are referring people for brain scans because of dizziness, and on the Internet it says they find inner ear dehydration is the cause.  B.K.

A: As I am sure you have seen from your Web searches, there are numerous reports of dry eye associated with Losartan as well as other medications that treat hypertension. This is a situation where your primary care and eye care provider need to work together to identify the cause of your dry eye while still addressing your other medical problems. Keep in mind that the combination of dry eye and dry mouth is also typical of Sjogren's syndrome, which can now be tested for more easily with the new SJO test.

Frankly, the current healthcare environment does not make troubleshooting medication interactions easy  most doctors focus on their own specialty. However, if you serve as the bridge between the two providers, your chances are better of finding an effective medication that does not cause problematic side effects. I strongly suggest that you not discontinue any medication without guidance from your doctor.  Dr. Arthur Epstein

Q: Medical marijuana is causing my dry eyes. Besides discontinuing marijuana use or using eye drops, what can be done to stop the dry eye symptoms caused by the marijuana?  N.G.

A: Thanks for my first question on medical marijuana! I have not heard of dryness associated with marijuana use, but admittedly, my experience is limited. With more states approving its use, it could become a more common and better recognized problem.

My feeling is that any effects of the marijuana are only worsening existing dry eye. A thorough work-up might allow the underlying cause  usually evaporative dry eye caused by dysfunction of the meibomian glands  to be addressed, permitting you to continue your treatment without problems.  Dr. Arthur Epstein

Q: I have suffered from dry eyes for five years and have lower punctal plugs. My eyes have always been manageable until I started taking certirizine for hayfever a few days ago. My eyes became really dry and refuse to go back to normal, even though I have stopped taking the cetirizine.

I take it every year, and it has never caused problems. Can it have long-lasting effects and all of a sudden become a problem?  C.G.

A: A common symptom of antihistamines such as cetirizine is a reduction of tears and increased dryness. This generally lasts only as long as you take the medication and then subsides fairly rapidly. In your case, it appears to be persisting longer than expected.

I would increase your use of wetting drops until your eyes return to normal, which is most likely. Other possibilities are that your dry eye condition has coincidentally become worse or perhaps that one or both punctal plugs have come out.  Dr. Arthur Epstein

Miscellaneous

Q: My ophthalmologist has determined that I have MGD (meibomian gland dysfunction). She has recommended Lipiflow. In your experience, does it reduce symptoms for most of your patients?  S.R.

A: It sounds like your doctor is very dry eye-astute. That's great. Lipiflow is a breakthrough technology for dry eye and is the definitive treatment for MGD. We now recognize MGD as either the primary or a contributing cause of dry eye in nearly 90 percent of patients.

A number of tests help establish the diagnosis, including: the LipiView, an interferometer that measures the thickness of necessary oil on the surface of the tears in nanometer increments; meibography, which lets us image the actual meibomian glands; and diagnostic manual expression of the glands, to see how they are actually working. Most clinicians combine these key tests with more standard dry eye testing to refine their therapeutic strategy.

Personally, I am a huge advocate of Lipiflow. I practice in Phoenix, one of the driest cities in the world. Lipiflow has become a mainstay of treatment of MGD and dry eye in our office, which focuses specifically on dry eye and ocular surface disorders. Our practice attracts patients from across Arizona and the Southwest, many of whom are desperate dry eye sufferers. We have had excellent success with Lipiflow, and in many cases the reduction in symptoms has been so profound that it has literally changed lives.

Like every other therapy, it doesn't work for every patent, but in my experience it is extremely beneficial for the overwhelming majority. I am sure your doctor will discuss pros and cons, but I will recommend that you carefully follow the recommended post-treatment instructions. I've found working with the doctor improves outcomes significantly. Once the glands are open and functional, blinking exercises and appropriate nutritional support can help keep them functioning.

Let us know how it works out for you.  Dr. Arthur Epstein

Q: At 50 years old, I finally need glasses. Because of the antidepressant Amitriptyline, I have dry eyes. My new glasses work great for a while, but then things get a little blurry until I use some eye drops. Is that normal with dry eyes?  T.

A: It's perfectly normal. The tear layer is critical to vision, and any disturbance to the tears can disrupt vision. I suggest you try a tear containing a lipid component like Allergan's Refresh Optive Advanced or Alcon's Systane Balance. They may gel-stabilize your vision for a longer period of time. If this persists you may want to have a complete eye exam to make sure nothing else is going on.  Dr. Arthur Epstein

Q: Why do my eyes burn like crazy if I tear up, or if water gets in them in the shower? (Or rain. Moisture in general.) My eyes don't feel dry. They just burn when any other moisture is introduced.  L.M.

A: Tears are optimized for an individual. They contain many different elements, like salts and proteins. On the other hand, water from the shower or rain is comparatively pure. The differences in salt and other elements can cause burning and irritation.  Dr. Arthur Epstein

Q: About two weeks ago I noticed large, red veins on the whites of my eye and was pretty worried. It turns out I have dry eye, based on some common dry eye symptoms.

The thing is, ever since I noticed that I had dry eye I noticed an uneven, wacky circle on the border of the iris and the pupil, and I'm wondering if I should go to the eye doctor or if it's just a common thing with dry eye. I am 16 years old.  J.

A: Don't try to diagnose yourself. What you are describing is unusual, and you need an eye doctor to figure out what it is. Dry eye is exceedingly uncommon in 16-year-olds.  Dr. Arthur Epstein

Q: I'm not sure if this is related to dry eyes, but I'm currently taking Accutane, and I know that this can cause dry eyes, which may be causing the problem. For a long time now I have constantly had around 10 floaters in my eyes almost all day, every day. I also seem to have flashing lights in my eyesight that do not blur my vision. And I have very small circles covering my whole field of vision  they're like tiny specks of light, like stars in the sky.

When I close my eyes I can see all the problems with my eyes even more clearly. There's basically lots of lights flashing in my vision, which is extremely annoying. I've been to several opticians, and they all send me back, saying I do not have a problem.

My vision is still 100 percent. I am taking three classes that all include computer work, I am also doing lots of homework on the computer, and most days I would say I'm on a computer for around 10 hours a day, which could have something to do with the problem.  L.A.

A: While Accutane is associated with dry eye, most of your symptoms are not. The floaters are likely coming from changes in the vitreous, the gel in the back of the eye. Likewise the flashing lights and little circles or "cells" you describe sound like entoptic phenomena, which are normal and often visible to astute observers.

Considering three eye care professionals gave you a clean bill of health, I assume you are fine. However, given the Accutane and your extensive computer use, I will make the recommendation of blink exercises to insure that you maintain proper meibomian gland function. If you have an iPhone, there is a blinking exercise app for it. A Google search for blinking exercise instructions would also be productive.  Dr. Arthur Epstein

Q: I have a persistent twitch in my right eye. One doctor says it's related to my dry eye, while a second doctor says it is not. Who is correct? I have not read any reports that eye twitching is caused by dry eye.  R.M.

A: A persistent twitch of the eyelid, also called myokymia, is not typically associated with dry eye. Most eye care practitioners attribute it to stress. Myokymia generally goes away by itself. Some doctors prescribe topical antihistamines, which may help it resolve more quickly.  Dr. Arthur Epstein

Q: Is it normal to see tissues floating (swimming) around your eyes? I must say, it sounds weird, but it can't be seen with the naked eye (I mean, from the outside). I've actually noticed it sometimes while walking or while typing some documents  I'll see some tissue-like patterns swim across my eyes lightly. Is this normal or symptoms of something?  M.

A: As we age, and especially in people who are nearsighted, the jelly-like substance in the back of the eye called the vitreous tends to liquify. Eventually it separates where it is loosely attached to the retina, and patients will sometimes see the debris float across their field of vision. What you are actually seeing are shadows rather than the actual strands of vitreous.

For most people, this is a normal part of aging, but vitreous detachments can sometimes tear the retina and lead to serious retinal detachment. For that reason, it would be wise to consult an eye care professional. If you notice any change like a sudden increase in these floaters, you should see an eye doctor urgently. In any case, this isn't a manifestation of dry eye.  Dr. Arthur Epstein

Q: I get very embarrassed concerning the crust I always have at the corners of my eyes. I have to keep wiping, and it is making the corners dark. What can I use other than over-the-counter eye drops for dry eyes?  B.

A: Although it's difficult to make a definitive diagnosis from a description alone, it sounds like you have angular blepharitis. Treatment requires topical antibiotics or an antibiotic-steroid combination.

I have also been having good success with a new eyelid cleansing product called Avenova with Neutrox in place of antibiotics. All of these treatments must be prescribed by a doctor, so it's time to arrange a visit.  Dr. Arthur Epstein

Q: My friend was diagnosed with dry eye and was told she might have to wash out her eye. What does the doctor mean when he says he will have to wash out her eyes?  D.

A: I recall that my mother had an eyewash cup that she would occasionally use with an over-the-counter product to wash out her eyes. However, that was many, many years ago, and we know much more now than we did back then. I don't know anyone who still recommends this today.

The reason is that the tears are very complex, and while we often use products to fortify or supplement them, in most cases nothing is better, more soothing or protective then natural tears.

Perhaps your friend misunderstood the doctor?  Dr. Arthur Epstein

Q: I have suffered from dry eyes for many years and have used various prescribed remedies but still suffer. I'm using Viscotears now, but my eyes are still dry and sore. Could it be the preservative in the products?  V.M.

A: Many patients are sensitive to preservatives. With dry eye, the volume of the tears is reduced, and the ability of the tears to dilute preservatives is minimized.

I am not completely familiar with what products are available in the UK, but I believe there are non-preserved dry eye preparations. I would one to see if it resolves your problem.  Dr. Arthur Epstein

Q: My eyes rarely tear. Even on some sad occasions my eyes do not drop a single tear. Is it unusual?  S.

A: Tearing varies among individuals; however, a complete lack of tearing is unusual and may be a sign of a possibly serious health problem, especially if it is of recent onset.

If you have always been this way it is probably normal, but it's still worth having an eye care specialist check your eyes.  Dr. Arthur Epstein

Q: Is it possible to have dry eye syndrome in one eye?  C.

A: It's much more likely to have dry eye in both eyes, with one much worse than the other. But it is possible to have dry eye in just one eye.  Dr. Arthur Epstein

Q: I cried a lot last night. I don't cry very often, but when I do my eyes are very swollen and dry the next day, and the dryness lasts all day. What do you recommend?  M.

A: Tears are very complex, and the tears that are made normally are very different than the tears that you make when you cry. I suspect that the "crying tears" are washing away the healthy, protective tears.

There are a number of products that might help, but because it was initially designed as a total tear replacement, I recommend you try Systane Balance made by Alcon Labs. It should help.  Dr. Arthur Epstein

Q: I've had dry eyes for about three months now. I've been to three doctors and one specialist. Two doctors said it was mild. The specialist said I have tears and to keep doing what I'm doing. Another doctor said it was chronic.

I'm using Lotemax and lubricants every two hours. My symptoms of burning are gone, and though my eyes are sore, they are definitely better and manageable now.

I've asked all the doctors if I'm going to go blind, and they have all said no. I'm still scared, though  I'm only 22. Should I believe the doctors and stop being fearful?  J.

A: You will not go blind from this, but what you are describing is not typical for someone your age. Long-term use of steroids like Lotemax is also not a good idea and can lead to serious eye health issues.

It might make sense to consult with someone who has a very strong focus on dry eye.  Dr. Arthur Epstein

Q: It doesn't happen often, but every now and then when I wake up, my left eye is extremely dry and bothersome. I use one of my strong headbands by wearing it "pirate style" (over the eye so that the eyelid cannot open), and within an hour or two, it is fine again.

What causes this? Is it some type of syndrome? Thank you for anything you can suggest, Doctor. It's more of a nuisance than anything else, and oh yes, tears can run freely from that dry eye, which really surprises me.

I've worn eyeglasses since I was 10 years old (I'm 73 now), and my left eye has always had less strength than the right eye.  M.K.

A: I am always amazed at the creativity of patients in solving their own problems. By patching the eye, you are preventing evaporation of the tears and allowing the ocular surface to recover and heal.

This is most likely caused by the lids not closing completely, resulting in exposure of the surface of the eye while you are sleeping. Excessive tearing is how your body tries to re-establish balance when the tears aren't effectively protecting the ocular surface. You may also have MGD (meibomian gland dysfunction), which can cause excessive evaporation.

For the nighttime issue, EyeEco makes a new silicone shield that protects the eyes during sleep and reduces the issues caused by exposure. You can find the product on the EyeEco website. Treatment should significantly improve your symptoms.  Dr. Arthur Epstein

Q: I am 74 and have been diagnosed with dry eyes. One eye does not exhibit any symptoms, but the other stays red and burns most of the time. Why the difference? I have been using Restasis for a year but cannot really tell a difference.  H.S.

A: Dry eye can affect one eye more than the other. Rarely, the difference can be as dramatic as you describe.

Restasis works wonders for some patients, but not at all for others. It can take a few months before it begins to work, but you have been on it long enough to know. It primarily targets inflammation, but there are many other causes of dry eye.

My suggestion is that you have your eye care provider re-evaluate your eyes to see if the cause of your problem can be diagnosed and remedied. Until then, I would increase wetting drop use in the worse eye.  Dr. Arthur Epstein

Q: I have been diagnosed with dry eyes. I purchased a microwave compress for my dry eyes. After using it, my eyes became quite blurry, and it frightened me. It lasted for several minutes. Is it good to do this home treatment?  B.

A: We now recognize that much of dry eye is caused by dysfunction of the meibomian glands, small glands in both upper and lower lids that produce a complex oil with each blink. In many patients these glands become obstructed and do not produce enough of these oils to maintain a stable tear structure or prevent evaporation.

From your description it sounds like you or your doctor was trying to address this issue. Application of heat helps melt the thickened oils, and massage helps get the now liquified oils flowing. What you are most likely experiencing is a sudden inrush of oil causing temporary blurring.

However, be careful. Recent evidence suggests the combination of heat and vigorous massage of the eyes can damage the collagen structure of the cornea. Also, excessive heat can burn the thin skin surrounding your eyes.

While a little temporary blurring is probably a sign of your efforts working, if the blurring worsens or you remain concerned about it, see your eye care professional.  Dr. Arthur Epstein

Q: I have dry eye and have had it for several years. Now I also seem to be having problems producing oils. I have had swollen oil glands in the past and tried LipiFlow, which helped some. I have been cleaning my lids with mild soap  that has helped a lot.

What other steps should I take? It seems apparent that my meibomian glands are tending to stop up. My eyes are driving me nuts.  R.H.

A: Welcome to the club. The overwhelming majority of patients who suffer from dry eye have dysfunction of the meibomian glands. Lipiflow is, in my opinion, currently the best and most effective means we have of treating this condition. As you note, the complex oil produced by these glands in both upper and lower lids are essential to a healthy and stable tear film.

I am not sure how long ago you had the LipiFlow treatment, but if it has been more than five or six months you might consider returning for lid debridement. This simple procedure helps the meibomian glands produce oils by clearing any external blockage.

Also, blink exercises are important post-treatment. The blink drives emptying of the oils in the glands, and poor or partial blinking can undo the benefits of the treatment. Apps are available to assist with proper blinking.

You also should be taking a quality EPA-based fish oil supplement. Continuing warm compresses and gentle massage after treatment may help. And the use of lipid emulation drops like Systane Balance or FreshKote may also help.

If it's been a year since your treatment, it may be time for another, although many patients experience longer-lasting relief from LipiFlow.  Dr. Arthur Epstein

Q: My doctor told me today that I have tear drops in my eyes. It happens in the latter part of the afternoon. Could you please explain, and tell me what can be done about it?  S.F.

A: Your question raises a great point. I truly do not know what your doctor is referring to. Virtually everyone has tears, and I have no idea what he meant by "tear drops."

It is very important that everyone make sure they fully understand what their doctor is telling them while they are in the office. Perhaps the most important part of caring for patients is communicating with them. I suggest you call your doctor's office and ask if they could call you to explain what he or she meant. Sorry I can't be more helpful.  Dr. Arthur Epstein

Q: I have had what seems like chronic dry eyes for over a month now. Is that long enough to damage my vision? I don't have any health insurance. I don't know when I'll be able to see an eye doctor for this problem. I'm only 37 years old, and this is really affecting my life right now.  D.

A: Sorry to hear of your problems. Dry eye is typically a slowly progressive problem, but some patients transition from asymptomatic to very symptomatic very quickly.

Dry eye can lead to damage of the front surface of the eye and cause reduced vision, but this isn't something that happens suddenly, so I wound not worry about it at this point.

I understand your situation, and there are a number of things you can do to treat your dry eye yourself. First, drops that supplement the natural tears. My first choices include Systane Balance and FreshKote. Systane Balance is available over the counter. To get FreshKote, which is not an Rx product, you may have to ask the pharmacist, as it is usually kept "behind the counter."

Make sure you are drinking sufficient water. Guidelines for water intake are available on the Internet. Nutritional supplements containing EPA may also be helpful.

I realize you do not have health insurance coverage, but if this gets much worse, it would be wise to consult an eye care practitioner to make sure that something more serious isn't contributing to your symptoms.  Dr. Arthur Epstein

Q: What under-eye cream do you recommend for eyes that are very dry and sensitive?  S.

A: As long as you don't get any of these creams directly in the eye, I do not believe they will adversely impact your dry eye. A brief Internet search will reveal a number of products designed for sensitive skin, which makes sense given your history. Be especially careful around the eyes, as products designed for skin may be irritating to the eyes, even if formulated for sensitive skin.

One other recommendation is that if you have also been diagnosed with blepharitis or meibomian gland dysfunction  which affect the lids  and lid scrubs using detergent pads or baby shampoo have been recommended, this may be removing too much natural oil from the skin around the eyes and can be causing drying and irritation.

If you wish to cleanse your lids, I recommend a soft terry cloth with no soap, only gentle rubbing to clear debris. If your eyes continue to bother you, a dry eye-friendly eye care provider may be able to help make you more comfortable.  Dr. Arthur Epstein

Q: I really appreciate you taking the time to answer questions like this! Hopefully it's something simple, but it's become quite a bothersome issue for me. For the last year or so, my left eye has been extremely dry. My right eye is fine, but the left eye is to the point where I'm going through more than a half-ounce bottle of lubricating eye drops every couple of days.

Not sure if it's a result of the dryness, but I have also noticed a red, raised area on the inner corner of my eye that is starting to budge into my iris. I can send you pictures if you would like when you reply.  A.G.

A: Thank you for the kind words. I really enjoy being here to answer questions and helping out as much as I can. I wish your question was an easy one to answer, but it's not. As you can imagine, it's sometimes very difficult to figure out what's going on with a patient's eye from a written description. And while a picture may be worth a thousand words in some cases, photos in the absence of a physical exam can sometimes be difficult to interpret.

In your case, the dryness you're experiencing may be caused by a number of problems. The reddish raised area you describe is of more concern. It may be as simple as irritation caused by dryness, it may be the cause of your discomfort, or it could be something more serious.

In any case, whenever something new or unusual appears on your eye and seems to be increasing in size, you need to have it checked by an eye care professional. It may be nothing, but with an examination, you can make sure it's not serious and get professional help for the dryness you're experiencing at the same time.  Dr. Arthur Epstein

Q: Can I have dry eye in one eye not the other? And can one eye hurt and be red more than the other?  J.

A: Having a problem affect one eye is usually more disruptive than when it occurs equally in both. For many people, dry eye affects both eyes more or less equally; for others, as you describe, it can affect one eye more than the other. For example, asymmetric tear production or increased tear drainage in one eye compared with the other can result in unequal discomfort.

Treating dry eye, whether in one or both eyes, first requires finding the cause. That will allow your eye care professional to treat the problem successfully.  Dr. Arthur Epstein

Q: How high should the percentage of humidity be in the room when dealing with severe dry eye syndrome?  P.

A: Higher humidity generally translates into less evaporation from the eye's surface. That's why many people have difficulty when moving to arid environments like Arizona, or during the winter when heating systems dry the air. It is also the reason why moisture goggles are prescribed for some patients with severe dry eye.

Also, its not just the ambient humidity, but the shock that occurs when transiting between high and low humidity environments  for example, the low humidity air-conditioned indoors and the hot and humid outdoors that occurs in many areas throughout the world during the summer months.

One last thing: The eye has a natural barrier to evaporation and environmental dryness. Meibomian glands present in both upper and lower lids produce complex oils that adhere to the tear film, creating an effective moisture barrier. If you are experiencing issues with dryness, it would be wise to have your eye care professional evaluate your lids and meibomian gland function.  Dr. Arthur Epstein

Q: I have severe dry eye. I've tried every eye drop and gel and still no relief. I would love to have surgery, but my insurance does not cover eye care unless it is for a medical reason. The insurance carrier said it needs to be put under a certain medical code.  K.M.

A: Dry eye is a medical condtion, and most insurance covers examinations and most, but not all, treatments for the disorder. For example, LipiFlow therapy for meibomian gland dysfunction is very helpful for many, but is not yet covered by most plans.

Speak to your eye care provider about what would work best to treat you and if insurance will cover it or if it is out of pocket.  Dr. Arthur Epstein

Q: Could you tell me if it's safe to use sulphonated castor oil as eye drops? Thanks so much  great website!  J.R.

A: Thanks for the kind words. As a general rule, you should avoid putting anything in your eyes that isn't specifically indicated and approved for that purpose. Non-sterile products can lead to infection or cause other problems.

Q: I have chronic dry eyes. I've been to three eye doctors, and nothing has worked. I wear sunglasses all the time to ease my eyes. What do you suggest?  J.H.

A: Sorry you are having so much difficulty in having your problems addressed. Without actually seeing a patient it is very difficult to tell what's going on or what has been tried previously and failed. From your note, its obvious that you are very uncomfortable.

The field of dry eye and ocular surface disease is evolving and expanding very quickly, and new approaches in technology have been recently introduced. For that reason I am hopeful that your issues can be resolved. My suggestion is to seek a clinician who focuses exclusively or extensively on dry eye.  Dr. Arthur Epstein

Nutrition and Dry Eyes

Q: I have had severe dry eye for several years. I am tired of punctal plugs because they keep falling out. I am thinking of trying increasing my water intake, plus taking omega-3. How much omega-3 per day is required? Also, is fish oil better or is flaxseed oil?

I have also been hearing a lot about GLA (gamma linolenic acid). Does it make a difference? If so, how much do I need?  R.O.

A: There are many opinions regarding nutritional supplements for dry eye. The general consensus is that they are effective for many patients through a number of mechanisms. Most clinicians recommend omega-3 fish oils, but individual dosing varies.

There is good evidence that supplements incorporating GLA are beneficial, and generally I recommend them.

Since nutritional products can vary tremendously in quality, I tend to recommend brand-name products. HydroEye by ScienceBased Health is a good example, but it's best to seek your doctor's recommendation.

Also, your plugs should not be falling out. Punctal plugs come in different sizes and designs, and if fitted properly they should last for quite some time. I suggest a visit to your eye care provider to have this checked and also evaluate the function of your meibomian glands. Persistent dry eye is usually at least partly evaporative in nature and can be effectively treated.  Dr. Arthur Epstein

Q: Do omega-3 capsules help provide relief from dry eye pain? Which capsules should I take, and at what dosage?  H.M.

A: Omega-3 supplementation is believed by many to be beneficial for patients suffering from dry eye. It has numerous effects on the ocular surface and the tears. I usually recommend 1000mg a day of a brand-name product, which ensures that the oil is pure and properly prepared.

Before starting, you should consult with your primary care physician or eye doctor to make sure you won't have any problems with the supplement.  Dr. Arthur Epstein

Q: Is it okay to take omega 3 fatty acids if you have a subconjunctival hemorrhage?  M.C.

A: That is an excellent question. For many years omega-3 supplements were thought to increase bleeding. While some clinicians still hold to that belief, current thinking is that there is little risk of increased bleeding with these supplements.

Since conjunctival hemorrhage resolves quickly, if you are at all concerned, discontinue the supplements until the hemorrhage fades away. An isolated conjunctival hemorrhage may be visually alarming, but it is generally nothing to be concerned about. However, if you are experiencing recurring conjunctival hemorrhages, you should consult your physician to determine the cause.  Dr. Arthur Epstein

Q: I have been taking the TruNature brand lutein and zeaxanthin supplement and would like to know if this should help with my dry eye condition. Also, I wonder if the titanium dioxide ingredient in this supplement is dangerous.  E.B.

A: Lutein and zeaxanthin are antioxidant carotenoids that are present in fruits and vegetables. Supplementation is thought to promote the health of the central area of vision known as the macula.

To my knowledge, zeaxanthin and lutein have little to no effect in ameliorating dry eye signs or symptoms, although I do not believe they would be harmful when taken in recommended amounts.

The use of titanium dioxide is somewhat controversial, with some data suggesting it may be carcinogenic when inhaled. I am unaware of any benefit or therapeutic value of this ingredient.  Dr. Arthur Epstein

Q: I've been experiencing dry eyes for about three years now. Recently, I discovered a lack of omega-3 fatty acids in my diet to be a possible cause. Taking fish oil capsules seemed to improve my condition greatly for about two weeks, after which my dry eye syndrome returned again. Is it possible dry eyes only temporarily benefit from increased omega-3 consumption, or should I look for another cause?  J.D.V.

A: Omega 3s are one of a group of essential fatty acids (EFAs) that serve a variety of important functions in the body. For many dry eye sufferers, omega-3 supplementation can be helpful, but it may not benefit everyone. Your only temporary improvement from omega-3 supplements suggests there are other possible factors that are contributing to your dry eye. I agree that further investigation is warranted.  Dr. Arthur Epstein

Ortho-K and Dry Eye

A: Thank you for the excellent question. Technically, dry eye is a contraindication to contact lens wear. However, many dry eye patients are still able to wear contact lenses successfully, provided that their ocular surface is healthy and their dry eye is not severe or has been successfully managed. This is especially true for ortho-K designs that are typically worn overnight.

You may also need to be followed more closely to insure that your eyes remain healthy. Your contact lens fitter should be able to determine your suitability for lens wear during the initial examination and fitting. Good luck!  Dr. Arthur Epstein

Other Diseases and Dry Eye

Q: I have very severe dry eyes. I've been tested for Sjogren's syndrome over and over again. I also have osteoarthritis in my back and shoulder, as shown on a bone scan.

My ophthalmologist said I have Sjogren's, even though I have had no other symptoms. She also said my tear ducts were not blocked. Artificial tears are not working. I used Restasis for six months or more, and that didn't work. So now I'm wondering what else could be done.

I'm looking for another ophthalmologist to get another opinion, as glaucoma runs in my family. I have inflammation in my body from arthritis, though no pain as long as I exercise daily. Could you give me your suggestions, please?  S.G.

A: First, I advise that you be retested for Sjogren's with the new Sjo test, which is more sensitive and definitive than prior testing by biopsy. I suspect it may prove your ophthalmologist correct. Ask your eye doctor about this test.

Restasis, while a godsend for some patients, doesn't work for all. OTC drops vary in mechanism, and you really need a knowledgeable professional to come up with a treatment plan. For the majority of patients, evaporative dry eye plays a large role in their overall symptoms. Until you find the right eye doctor, you might try drops that contain a lipid supplement, like Systane Balance or Allergan's Refresh Optive Advanced Formula.  Dr. Arthur Epstein

Q: My husband is paralyzed and ventilator-dependent. He was misdiagnosed with ALS but actually has Lyme disease and was put on a ventilator in error many years ago.

That said, his eyes do not blink, but he can close them at night and open them. His eyes get severely dry, as you can imagine. We have tried all the gels, natural eye drops, etc. We tape his eyes closed at night, and he wears goggles that have sponges in the sides that we moisten.

After trial and error, we found that the gels were drying on his eyes, because when his eyes are inflamed and irritated it is uncomfortable to move his eyes around.

Long story short, after meeting with the eye doctor, with a regimen of cleaning the eye with saline solution, using an eye drop with mineral oil (Systane Balance) and occasionally using Lotemax when red and painful, his eyes have been less irritated. Because of my husband's misdiagnosis and inability to move, his eyes are his major source of communication while rehabilitating.

So, while things are better we still need a lot of help. His eyes are not moving well when they are in pain or dry like sandpaper. When his eyes feel great, they move great. He feels that his eyes see clearly. All he can do is watch TV all day, so I'm sure he has eye strain too.

My husband internally is healthy, and his brain is working fabulously. He manages to be a happy man, and we are happy to have him here.

I am wondering if possibly he is getting eyelid infections, too. He has been on antibiotics for eye infection, and then when the infection is cleared, his eyes seem fabulous: bright-eyed and bushy-tailed. Could he be getting constant infections because eyes don't blink?

I need some relief for him. He is such a champ.  D.B.

A: I am so sorry to hear about your family's problems. Your story hits home, as my eldest daughter contracted Lyme disease as a child, and we endured a long and arduous series of treatments. Sadly, Lyme is all too frequently misdiagnosed and under-treated.

I will try to make my answer as concise as possible. First, please know that you are already doing many of the right things, and I know you have helped your husband tremendously. I suspect that evaporative dry eye is the root of most of his problems. Meibomian glands run radially down both upper and lower lids and function through the action of the blink. They produce complex oils that keep the tears from evaporating, provide lubrication and serve a number of other important functions.

In the absence of blinking, the glands can't push these oils out, and they stagnate and become thick, eventually obstructing the glands completely. If not treated, the blockage can lead to atrophy of the glands and ultimately permanent gland loss.

The definitive treatment for meibomian gland dysfunction is LipiFlow, a procedure pioneered by TearScience. I might suggest that you look into it.

There are other, perhaps somewhat less effective ways of approaching this, including regular gland expression, which can be taught to you by a willing eye care professional. Moisture shields and moisture goggles are also key to his management. EyeEco, a California company specializing in dry eye products, just introduced a silicone shield that I would recommend for nighttime use. It serves as a moisture barrier and also helps prevent mechanical irritation and drying. They also make a moist heat product that sounds similar to what you are already using.

Other treatments that may be useful (depending on his condition) include topical Azasite and oral doxycycline. Both are antibiotics but have additional anti-inflammatory properties. They must be prescribed by a doctor, but only if his condition warrants.

I also would be inclined to have him take an omega-3 supplement. HydroEye by Science Based Health and Omega Dry Eye Benefits are two excellent products if he has no contraindications to them.

Perhaps the most important advice I can offer is to make sure he is under the care of an eye care specialist who has an intense focus in dry eye and ocular surface disease. His situation is complex and must be managed carefully. I hope this helped.  Dr. Arthur Epstein

Q: I have suffered from a disease called TEN (toxic epidermal necrolysis). It has been about two years since I was released from the hospital, but I am still having a lot of trouble with my eyes. They're very sensitive to the sun and very dry all the time.

They said that my eyes can't produce tears because they have been so damaged. It's hard for me to go about a normal day. I have so many problems with my eyes every day. I am past the hope that my eyes will ever be normal again, but I just want them to be better.

Is there any way that you can repair my eyes to produce tears again or anything that would at least make them better somehow? Every eye doctor I have seen has never had someone with my problems.  J.M.

A: TEN syndrome is thankfully rare, but as you unfortunately know first-hand, extremely damaging to the body. The eyes can be severely affected, with damage to both structure and normal function.

There are many therapeutic strategies that might be helpful to you, but a thorough exam would be necessary to better understand what would best help. Since your problems are so severe, scleral contact lenses  sometimes referred to as PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem) are a possibility. These large lenses offer protection and restoration of sight and function.

I can only imagine how difficult this is, but I truly believe that you can be helped.  Dr. Arthur Epstein

Q: I am getting desperate. I have severely dry eyes (Sjogren's syndrome), and they seem to get worse every day. I have sharp stabbing pains in them. I cannot tolerate wind of any kind and bright lights. I put eye drops into them throughout the day.

My doctor did prescribe Restasis for me. It has helped some. But I can no longer read books, paper, etc. Watching too much TV and doing computer work bother a lot as well.

What should be my next step to get relief?  K.B.

A: Sjogren's syndrome can cause very severe dry eye by attacking the tear-producing lacrimal glands and reducing tear production. This can also cause visual disturbance, as you are experiencing. Often, other factors contribute to the problem, and when addressed, that can help.

Newer approaches that minimize evaporation of the limited tears you have and even special contact lenses can bring substantial relief. More and more eye care providers are focusing on dry eye disease. It is important that you find one with the experience and resources to identify and address all of the issues that are contributing to your misery.  Dr. Arthur Epstein

Permanent Cures for Dry Eyes

Q: Is there any permanent cure for dry eyes without using eye drops? I also would like to know the cause and long-term adverse results of dry eyes. Does the condition damage the cornea of the eye? Does it reduce vision? I have tried everything, but I'm not getting any relief.  V.S.

A: Dry eye is a chronic condition that requires treatment with various types of drops. Oral omega-3 fatty acids are a nutritional supplement that may be all that is needed for mild dry eye treatment. Otherwise, treatments for dry eye are typically in drop form. So it would be difficult to avoid the use of drops for treating dry eye.

As far as what happens if dry eye is not adequately treated, chronic dry eye over time can be progressive and can lead to fluctuating vision and loss of quality of vision. For severe chronic dry eye, treatment is important to avoid visual problems down the road. So please see your doctor to figure out your next steps for treating your condition.  Dr. William Trattler

Punctal Cautery

Q: I tried Restasis for two years for dry eyes, with no luck. Is tear duct laser surgery a good idea? Is it safe and reversible?  G.G.

A: Restasis is a very effective drug for some patients, but it doesn't work for all. Likewise, punctal occlusion can be very helpful, but can also cause myriad problems.

If you or your doctor are considering laser or conventional cautery of the puncta (tear drains), it is extremely important to first confirm the effectiveness and benefit of this approach by using temporary occlusion before performing a permanent procedure.

You should also evaluate other possible causes of your problem before considering a permanently occluding drainage.  Dr. Arthur Epstein

Punctal Plugs

Q: I wear contacts and suffer from dry eye. Would I benefit from punctal plugs? Currently I use contact re-wetting drops. At one time I used Restasis.  C.

A: Without examining you, it's hard to say whether punctal plugs would be helpful. Diagnosing and treating underlying dry eye is important. However, contact lens wearers will also benefit more from switching to single-use disposable lenses like the new Alcon Dailies Total One in terms of improved comfort than from most other strategies.  Dr. Arthur Epstein

A: According to the Restasis FDA labeling, the product will not help patients who have punctal plugs. However, each person is different and some doctors believe that using both simultaneously can be helpful.  Dr. Arthur Epstein

Q: Can tear duct plugs cause extreme sinus dryness?  J.F.

A: Sinus dryness would be a very unusual side effect of punctal plugs. Dryness of the eye and mucous membranes, which could possibly manifest as sinus dryness, may be a sign of a systemic disorder  specifically, Sjogren's syndrome. I would consult with your eye care provider. A simple test, Sjo, was recently introduced to detect this condition.  Dr. Arthur Epstein

Q: I had an eye plug inserted into my left eye for dry eye three months ago, and it has been very successful. We are in the midst of a very bad allergy season, and everything is bothering me.

I looked at my eyes in a magnifying mirror, and it looked as if the plug was coming out, so I got a needle and gently poked it down. But the plug disappeared into the tear duct, and now I can't see it.

I'm pretty embarrassed about this, but I want to make sure I'll be OK. Will I?  D.

You can see in this anatomical slideshow three different shapes of punctal plugs. Images: Oasis Medical, Inc.

A: Some plugs fit totally inside the canal. Others are designed to be anchored in place but are prevented from slipping all the way in by a dome or crown. From your description, it sounds like you had the latter type.

Punctal plugs come in different sizes, and a properly fitted one should stay in place, neither protruding and causing irritation or slipping inside the canal where it cannot be seen. While using a needle near your eye is always a bad idea, it should not have been that easy to push the plug all the way into the punctal opening if it were properly sized.

At this point, I strongly suggest that you not manipulate the plug yourself any further and that you return to your doctor so they can take a look and possibly see where it is. It may still be possible to remove it relatively easily, but not if you push it further in.

The plug may stay in place quietly and continue to do its job without further problem, but it also may cause a significant inflammatory reaction. If it does, it may have to be removed by irrigation or possibly surgery.

When you are at the doctor's, ask them to prescribe a prescription allergy drop. Modern prescription allergy eye drops are extremely effective and will dramatically reduce allergy symptoms. I hope everything turns out okay.  Dr. Arthur Epstein

Q: I have lower punctal plugs in both my eyes, and my dry eyes have not improved at all. I cannot take fish oil supplements, because I am allergic to them. My eyes are constantly red 24/7 and hurt.

Is there anything else you can recommend I do to alleviate my symptoms, especially my red eyes? I was on Restasis for a year before the punctal plugs were inserted, and it didn't seem to help. Should I try Restasis again with the punctal plugs?  L.K.

A: Without examining you it is impossible to accurately diagnose your problem; however, based on your symptoms and history, I would suspect meibomian gland dysfunction is either a cause or a contributing factor. The labeling on Restasis clearly states that it will not help patients who have undergone punctal occlusion. I do not think retrying it will help.

Since this has gone on for so long, I would urge you to find a dry eye-savvy eye care provider and have a complete dry eye workup.  Dr. Arthur Epstein

Q: I had tear duct plugs put in my eyes a few years ago. I suffered a head injury, and somehow it affected my tear production. The plugs helped my right eye, but not my left. This time of year, it being so cold and dry outside, my eye really bothers me. Is there anything else I can do besides using artificial tears to help my eye?  M.

A: Over the past few years our understanding of dry eye and the ocular surface has increased tremendously. There are now many ways to approach dry eye beyond artificial tears and punctal plugs.

Given your complex history, I would suggest that you consult with an eye care professional who is dry eye-focused. Your state has a number of excellent dry eye specialists.  Dr. Arthur Epstein

Q: What is the success rate of comfort plugs for dry eye relief after LASIK eye surgery?  M.

A: By comfort plugs, I assume you are generally referring to punctal plugs used to reduce tear drainage in cases of insufficient tear production or excessive or rapid evaporation. LASIK can reduce tear production in some patients. Although this typically resolves with time, treatment is often necessary, at least initially.

Unfortunately there is no way to know how you would respond to punctal plugs without understanding the underlying cause of your dryness or what factors may be contributing to it. Plugs are used less frequently these days, reflecting a better understanding of the causes of dry eye, the contribution of meibomian gland dysfunction to dryness, and a more targeted approach thanks to advances in therapy.  Dr. Arthur Epstein

Q: I was diagnosed with dry eyes, and it is killing me day by day. I have had the plugs, but they do not help. Seems like nothing helps. What can I do?  M.

A: Dry eye can turn your life upside down. Punctal plugs don't work for everyone, so please don't get frustrated just because they didn't work for you.

Since this is a major problem for you, a systematic approach is essential. Starting with a complete health history, you need a thorough workup of your eyes to determine the cause of the dryness. With a targeted approach, most dry eye problems can be eased if not mostly resolved.

Find someone in your area who is dry eye savvy and focuses a good part of their practice on dry eye. Solutions today range from advanced drops to prescription medication to state-of-the-art therapies like the Lipiflow by TearScience. I believe that there is a solution to your problem. Don't give up.  Dr. Arthur Epstein

Vision Problems Related to Dry Eyes

Q: I have seen the eye doctor several times in the last few months. My eyes are dry every morning, and they are starting to hurt. I see little white circles sometimes at night, right in the center of my field of vision. I also have noticed more than the usual number of floaters. They say it's just dry eyes, but will this ever go away? I didn't have this last year.  P.M.

A: It's hard to tell what's going on, from the information you provided. Dry eye can degrade vision, but should not be associated with visual phenomena like the white circles or the floaters you describe. It seems likely that you have a few problems occurring at the same time that may not all be related.

You need a thorough examination, including a dilated exam of the back of the eye, to make sure everything is okay there. You didn't mention treatment, but if you have been diagnosed with dry eye you should have been advised on how to treat your specific problem. I suggest you consult with the doctor who last saw you for more specific advice.  Dr. Arthur Epstein

Q: I have an extremely dry eye (right, dominant, astigmatism in left), which seems to have mucus on one spot and which gets very disturbing, because my vision gets blurred. And since my right eye is the dominant one, I am in trouble. What can I do? I put drops in all day long  I have them all over the house. Nothing seems to help.  M.M.

A: The eye will often produce excess mucus as a protective mechanism to prolonged irritation. In your case, chronic dry eye would seem the likely culprit. Tear evaporation caused by meibomian gland dysfunction is a likely cause or contributing factor.

Since regular drops aren't working and this sounds extremely distressing to you, you should consult an eye care professional. There are a number of new things available to treat dry eye that should be able to help you.  Dr. Arthur Epstein

Q: Is seeing glare normal for a person who has dry eyes?  J.C.

A: Dry eye affects the tear layer, which in turn can cause disturbed vision. Glare is not a common complaint associated with dry eye in my experience, but depending upon the cause of your dry eye, glare may occur. However, it can also be caused by other eye conditions, like cataract, corneal irregularity and scars, and retinal problems.

So it would be wise to consult an eye care professional to confirm the cause and ways to treat the problem.  Dr. Arthur Epstein

Q: Can dry eye or eyestrain reduce the eyes' power?  M.

A: That is a wonderfully perceptive question. The tears are quite complex. Among their primary functions is to provide a smooth and clear optical surface to focus light for the eye. Dry eye usually disrupts the tear structure, which can negatively impact vision and lead to eye strain. Treating dry eye is important not just to insure comfort and health but to provide the sharpest and most comfortable vision.  Dr. Arthur Epstein

Q: I have been suffering mild dry eyes for the past two years. Every six months my lens power keeps increasing. Does it relate to my dry eye problem? I am 21.  K.H.

A: While dry eye, and in particular evaporative dry eye (due to meibomian gland dysfunction) can impact quality of vision, it is unlikely to be a significant factor in myopic progression (increasing nearsightedness).

Most experts believe that myopia is generally associated with excessive near work and computer tasks. Approaches that halt the progression of myopia are being extensively investigated, but presently no truly effective approach has been found.  Dr. Arthur Epstein

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